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PUBLIC HEALTH ADMINISTRATION AND 
 
 m 
 
 THE NATURAL HISTORY OF DISEASE 
 IN BALTIMORE, MARYLAND 
 
 1797-1920 
 
 BY 
 
 William Travis Howard, Jr., M. D. 
 
 'HF IIRHftRY Of ■» l 
 DEC 1 2 1924 
 
 UNIVERSITY OF ILLINOIS 
 
 Published by the Carnegie Institution of Washington 
 Washington, September, 1924 
 
CARNEGIE INSTITUTION OF WASHINGTON 
 
 Publication No. 351 
 
 jSorfc Q^afftmore (press 
 
 BALTIMORE, MD., 0. S. A. 
 

 
 3 
 
 <r 
 
 r> 
 
 PREFACE. 
 
 In this work the author has attempted to portray the development of the 
 laws and practices of public-health administration in Baltimore, to trace the 
 ideas underlying their origin and gradual evolution, to inquire into the natural 
 history of those diseases which may be followed in the records of the Health 
 Department, and, finally, to correlate as closely as possible all the ascertainable 
 factors that may have influenced their courses. For the latter purpose, it has 
 been necessary to present in some detail the essential facts concerning the 
 location, origin, and growth of the city, the medical profession, the hospitals 
 and other public agencies, the dwellings, and the growth and racial composition 
 of the population. 
 
 The foundations of this study were laid for very practical reasons, during 
 the author’s service as assistant commissioner of health for the four years 
 ending in the autumn of 1919. The first two years of the period were crowded 
 with the details of administration, which necessitated intimate acquaintance 
 with the history, the personnel, and the activities of each and every bureau and 
 division of the health department. During the last two years, through the 
 broadmindedness and interest of Mayor James H. Preston, who readily appre¬ 
 ciated the importance of accurate study, by epidemiological and statistical 
 methods, of the natural history of the diseases the city was undertaking to 
 combat, provision was made for relief from administrative detail. 
 
 Beginning with typhoid fever and tuberculosis, systematic studies were 
 made of the common communicable diseases, in turn, by mortality since 1827 
 and by morbidity since 1898. Studies of poliomyelitis, tuberculosis, typhoid 
 fever, influenza, infant mortality, accidents, and of the influence of race stock 
 upon mortality of various diseases were published in the annual reports for 
 1916, 1917, and 1918. 
 
 These studies were directed primarily to three main objectives, namely, the 
 elucidation of the actual problems of disease control, critical appraisal of the 
 efficacy of the methods in use, and modification and further development of 
 methods in the light of knowledge that might be gained. Investigation soon 
 disclosed truths which lead to conclusions at variance with many accepted 
 doctrines and practices of public-health administration. It soon became evi¬ 
 dent that in many respects the game is far more cunning than its would-be 
 trappers, and that the problems of control and extinction of many of the com¬ 
 municable diseases are concerned with great and fundamental problems of 
 general biology far transcending present knowledge and the solution of which 
 lies beyond the scope of present-day health officials and sanitarians in general. 
 Some of the advice offered as the result of these studies was accepted, but 
 much was rejected as too unorthodox. 
 
 It was Professor Raymond Pearl who first appreciated the real value of the 
 data thus collected and who suggested that the scope of the investigation be 
 expanded and the results published in book form. To this end, among others, 
 his invitation in the autumn of 1919 to join his staff was heartily welcomed. 
 In November of that year the statistical and historical data, with many of the 
 
 m 
 
 562420 
 
IV 
 
 PREFACE 
 
 personal notes of the author on local epidemics of recent years, were destroyed 
 by fire. The work was begun anew and on a wider scale. 
 
 Some explanation of the groupings of certain communicable diseases here 
 adopted is necessary. The division of these affections into nuisance-borne and 
 contactive was dictated by historical and administrative as well as by analogical 
 reasons. The author is not unaware of the facts that many of the diseases classi¬ 
 fied in this work as nuisance-borne—the acute intestinal diseases, for example— 
 may be and often are spread by contact, and some of those listed among the 
 contactive affections are capable of being spread by other means. In spite of its 
 obvious drawbacks, this old distinction still possesses many notable advantages. 
 
 Many and perhaps indeed most of the observations recorded and the con¬ 
 clusions reached in this work are not new in the sense that they have not been 
 made before. Whatever of value this work may possess in these respects lies in 
 the variety, extent, and comparative accuracy of the original data in regard to 
 the particular diseases and to total mortality, the critical care with which they 
 have been sifted, and their correlation with public-health activities over so long 
 a period of time. It is hoped that, quite independent of the use made of these 
 statistical data in this work, inquiring students of statistics, of medicine, and of 
 public health may find in them material convenient for their several purposes. 
 The author is conscious that much of this material deserves wider and more 
 refined treatment by statistical methods than is here attempted, and hopes 
 that this store of biological data thus made generally available may prove useful 
 to others more capable in the practice of such methods. 
 
 The arithmetical work has been done with the greatest care and checked 
 several times, but, in calculations on such a large scale, it is not improbable that 
 occasional mistakes have crept in. However, all the factors necessary for their 
 proof are given in appropriate tables. In order to keep this work within reason¬ 
 able bounds, the temptation to make comparisons with other places has been 
 studiously restrained. 
 
 While gratefully acknowledging his deep indebtedness to his associates for 
 advice and criticism, without which this work would not have been possible, the 
 author assumes full responsibility for the opinions expressed and for the con¬ 
 clusions reached. 
 
 To his colleague and dear friend, Professor Raymond Pearl, for his generous 
 counsel, guidance, and criticism and for the opportunity to work under his 
 stimulating aegis, the heartiest thanks are tendered. 
 
 For information and advice the author is under deep obligations to many 
 associates in the department of health and to his colleagues in the department 
 of biometry and vital statistics, and among the latter Drs. Lowell J. Reed and 
 John Rice Minor are especially to be mentioned. Last and by no means least, 
 the author acknowledges with gratitude his debt to his secretary, Miss Audrey 
 W. Davis, for faithful and painstaking help in securing and tabulating data 
 and in calculating rates, and above all for indispensable assistance in the ar¬ 
 rangement and composition of this work. 
 
 William Travis Howard, Jr. 
 
 Department of Biometry and Vital Statistics, 
 
 School of Hygiene and Public Health, The 
 Johns Hopkins University. 
 
 Baltimore, Maryland, March 7, 1923. 
 
CONTENTS. 
 
 Part I. Certain Physical and Sociological Data Concerning Baltimore. 
 
 page 
 
 Chapter 1. 1 
 
 Location and topography; Settlement and growth in area; Factors deter¬ 
 mining expansion in commerce, industry, and wealth; Forms of 
 government; Meteorology. (Maps 1 and 2; Tables 1 to 3.) 
 
 Chapter II. 11 
 
 Physicians; Medical education; Hospitals and dispensaries; Charities; 
 
 Schools; Dwellings. 
 
 Part II. Historical Development of the Health Department and of Health Laws 
 and Regulations in Baltimore and the State of Maryland. 
 
 Chapter III. Ideas Underlying the Public Health Laws of Baltimore. 33 
 
 Chapter IV. Evolution of the Public Health Laws. 47 
 
 1. Baltimore Town 
 
 2. Baltimore City: The two fundamental ordinances of 1797, Ordinance 
 
 No. 11 and subsequent amendments and additions dealing with the 
 organization of the health department and the duties and powers of 
 health officials, the reporting and isolation of cases of communicable 
 diseases within the city, quarantine of the port; Hospitals controlled 
 by the city and the registration of births and deaths, and of physicians, 
 midwives, and undertakers; Ordinance No. 15 and subsequent amend¬ 
 ments and additions dealing with nuisances, namely: General sanita¬ 
 tion on public domains—street cleaning, garbage, night-soil collection 
 and disposal, food control—and sanitation on private domains—privies, 
 cesspools, night-soil, standing water, and decaying materials, cellars, 
 manufactories injurious to health, garbage, habitations, plumbing, 
 foods. 
 
 3. State of Maryland: Contagious and infectious diseases; Vaccination; 
 
 Medical practice; Registration and licensing of midwives; Pharma¬ 
 cists; Nurses, plumbers, undertakers, and barbers; Registration of 
 births and deaths; Lunacy commission; Child and other labor laws; 
 
 General nuisances; Foods; Building inspection. 
 
 Part III. Public Health Administration of Baltimore. 
 
 Chapter V. Public Health Measures without the City. 83 
 
 Development of quarantine laws and practices; Lazaretto and quarantine 
 hospitals of the Port of Baltimore; Effectiveness of maritime quaran¬ 
 tine. 
 
 Chapter VI. Public Health Administration within the City. 97 
 
 I. Introduction: Developments and accomplishments of public-health 
 
 practice in the nineteenth century based upon ideas and methods long 
 existent and determined very largely by the more general diffusion of 
 knowledge and wealth among peoples of intellectual and personal free¬ 
 dom; Influence of modern micro-parasitology; Reasons for vigorous 
 attacks on nuisances rather than on contactive diseases. 
 
 II. Measures of nuisance prevention and abatement directed against 
 nuisance-borne diseases: Definition of nuisance; Prevention and 
 abatement of nuisances on public property—Dredging and filling; 
 
 Grading and paving; Street cleaning and garbage removal; Sewerage; 
 
 Water; Food; Prevention and abatement of nuisances on private 
 property—Standing water; Organic material; Manufactories, habita¬ 
 tions. 
 
 III. Measures of restriction directed against contagious diseases: Isolation, 
 inoculation, and disinfection. (Tables 4 to 6.) 
 
 v 
 
VI 
 
 CONTENTS 
 
 PAGE 
 
 Chapter VII. The Administrative Officers and Subdivisions of the Health 
 
 Department .1. 157 
 
 Commissioners of health; Vaccine physicians or health wardens; Division 
 of statistics; Plumbing division; Laboratories; Inspection of school 
 children; Nursing bureau; Bureau of communicable diseases; 
 
 Bureau of infant welfare; Miscellaneous services. (Tables 7 and S.) 
 
 Part IV. Population and Statistical Data. 
 
 Chapter VIII. 173 
 
 1. Population: Rate of growth; Racial composition; Distribution by 
 
 numbers, sex, and race. (Tables 9 to 13, Graph 1.) 
 
 2. Natality: Living births; Still-births. (Tables 10 to 15 and 124, 126, 132.) 
 
 Chapter IX. Statistical Material. 191 
 
 Character; Sources; Uses; Methods. 
 
 Part V. Febrile Diseases. 
 
 Chapter X. Nuisance Diseases . 199 
 
 1. Insect-borne diseases: Malaria; Yellow fever; Typhus fever. (Tables 
 
 16 to 18, Graphs 2 to 4.) 
 
 2. Acute inflammatory affections of the intestinal tract characterized by 
 
 frequent loose stools of abnormal composition; Diarrhoea; Dysentery; 
 
 Asiatic cholera; Typhoid fever. (Tables 19 to 33, Graphs 5 to 10.) 
 
 Chapter XI. Typically Contactive Diseases.. 275 
 
 1. Acute exanthematous diseases: Small-pox; Cow-pox; Chicken-pox; 
 
 Scarlet fever; Measles; Influenza. (Tables 34 to 59, Graphs 11 to 16.) 
 
 2. Acute inflammatory affections of the respiratory tract: Whooping-cough; 
 
 Diphtheria; Pneumonia. (Tables 60 to 77, Graphs 17 to 20.) 
 
 3. Tuberculosis. (Tables 78 to 90, Graphs 21 to 26.) 
 
 Chapter XII. Other Acute Infectious Diseases, some apparently Contactive... 418 
 Acute meningitis; Poliomyelitis; Tetanus and erysipelas; Appendicitis. 
 
 (Tables 91 to 100 and 34, 128, 131.) 
 
 Part VI. Various Chronic Organic Diseases. 
 
 Chapter XIII. Tumors. (Tables 101 to 109, Graphs 27 to 29.). 435 
 
 Chapter XIV. Diseases of the Cardio-Vascular-Renal System. (Tables 101, 110 
 
 to 116, Graphs 27 to 29.). 454 
 
 Chapter XV. Diseases of the Central Nervous System and Liver. 469 
 
 Diabetes; Alcoholism. (Tables 117 to 119.) 
 
 Part VII. Miscellaneous Causes of Death. 
 
 Chapter XVI. Violence. (Tables 120 to 123, Graphs 30 to 32.). * 479 
 
 Chapter XVII. Child-birth. (Tables 124 to 127, Graphs 33 to 34.). 487 
 
 Chapter XVIII. Ill-defined Causes. 498 
 
 Diseases of early infancy; Arthritis; Hernia and intestinal obstruction. 
 
 (Tables 128 to 131.) 
 
 Part VIII. General Conclusions. 
 
 Chapter XIX. Deaths from All Causes. (Tables 132 to 139, Graphs 35 to 41.).. 507 
 
 Chapter XX. Summary and Conclusions. 531 
 
 Febrile diseases; Affections peculiar to child-birth and to early infancy; 
 Violence; Chronic organic diseases. (Tables 140 and 141.) 
 
 Bibliography . 563 
 
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 MAP OF BALTIMORE, 1801. 
 
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 Enyravec/ t>p Trane i s 5ha Jlu& PKbi 
 
PART I.—PHYSICAL AND SOCIOLOGICAL DATA 
 
 CONCERNING BALTIMORE. 
 
 Chapter I. 
 
 Location and topography; Settlement and growth in area; Factors de¬ 
 termining expansion in commerce, industry, and wealth; Forms of govern¬ 
 ment; Meteorology. (Maps 1 and 2; Tables 1 to 3.) (1 to 8.) 1 
 
 LOCATION AND TOPOGRAPHY. 
 
 Baltimore, the chief city of the State of Maryland and of the southern At¬ 
 lantic seaboard, is situated in latitude 39° 17' N. and longitude 76° 37' W., on 
 the Patapsco River and the Middle and Northwest Branches, at the point where 
 these join to form a broad and deep estuary leading directly to the Chesapeake 
 Bay some 12 miles distant. At the head of tidewater, 172 miles from the At¬ 
 lantic Ocean, from which it is approached over a great and easily navigable 
 inland sea, with safe and ample harbor and convenient piers and with good 
 communications with a territory rich in natural and developed resources, it 
 occupies an important strategic position as a port of entry, exit, and distribu¬ 
 tion for domestic and foreign trade. Its past, present, and future are intimately 
 bound up with these circumstances. 
 
 A second attribute of deep significance dependent upon physical geographical 
 characters is the city's situation on the fall line, at the junction of the alluvial 
 and Piedmont soils, or where the water-laid coastal and the granitic forma¬ 
 tions meet. Indeed, the city straddles these, its lower portion, or water front, 
 being on the former, and its larger and higher sections resting on the latter. 
 Away from the water front the soil consists of clay and sand hills covered in 
 many places with a thick coat of gravel. This series of hills, rising from 10 to 
 nearly 200 feet above tide, has in the main a northeast and southwest direction. 
 Between them course in a general northerly and southerly direction five 
 streams. Two, Harford Run and Jones Falls, running through deep and some¬ 
 what irregular valleys and carrying considerable volumes of water, empty into 
 the Northwestern Branch or Basin; the other three, Rutter's Run and 
 Schroeder's Run, both comparatively small, and the larger Gwynn's Falls dis¬ 
 charge into the Middle Branch. 
 
 Gwynn's Falls is near the extreme western boundary and Jones Falls bisects 
 the city into two nearly equal parts, the eastern and the western sides. In 
 earlier days, before the city was built up, a number of smaller brooks fed from 
 springs, and coursing through narrow valleys between the hills, discharged, 
 either directly or indirectly by means of the above-mentioned streams, into the 
 basin or into the Middle Branch. These and other topographical features yet 
 to be described may be followed on maps 1 and 2. 
 
 At different periods in the city's history all these streams, with the exception 
 of Gwynn's Falls, have been covered over. Originally the valley of Jones Falls, 
 
 1 Figures in parenthesis refer to bibliography at end of this volume. 
 
 1 
 
2 
 
 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 the most important stream, rose rather sharply to the hills on its west side, but 
 spread out widely with a comparatively flat surface for some distance on its 
 eastern side. No high hills separated the valley of Harford Eun from that of 
 Jones Falls; indeed, it appears that these two streams shared the same valley 
 over much of their courses through the site of Baltimore. At a comparatively 
 short distance from the water-front, the east side of the valley of Harford Eun 
 rose somewhat gradually to meet a series of high hills. The consequence is that 
 with the grading that accompanied the development of the city, the descent to 
 this combined valley, over a certain large area, is abrupt on the west and gradual 
 on the east side. The formation above described in the higher portions of the 
 city is well adapted to surface drainage, both from north to south and from 
 east to west. All of these streams, and Jones Falls in particular, were fre¬ 
 quently subject to overflow after very heavy rains, and as the city grew it be¬ 
 came necessary to wall their banks and in some instances to straighten their 
 courses. In earlier days these streams were of great importance on other ac¬ 
 counts; both G wynn’s and Jones Falls were used to turn mills, the latter being 
 for a long time an important source of water-supply. All of them have served 
 continuously as storm-water sewers and until recent years, in varying degree, 
 as sanitary sewers as well. 
 
 Turning now to the water-front, the land between the basin and the first 
 range of hills to the north was comparatively low, hut sloping in a general way 
 from north to south. Near the mouths of the streams, along the shores of the 
 basin and on those of the Middle Branch (Spring Gardens), there were wide 
 marshes, which for many years were sources of nuisance. Between the western 
 side of the basin and the Patapsco Eiver there projects a long tongue of land, 
 Whetstone Point, marked at its base by a towering hill (Federal Hill) and along 
 its center from base to tip by a ridge from each side of which the surface in¬ 
 clines to the water. At its southern extremity is situated the famous Fort Mc¬ 
 Henry. This comparatively narrow strip of land forms the southwestern bound¬ 
 ary of the old harbor, and from early days its eastern side has been the seat of 
 important docks and terminals, as well as shipbuilding and other kindred ac¬ 
 tivities. Opposite a point of land (Locust Point) which projects from about 
 the center of the northern shore of Whetstone Point, lies Fell’s Point, the 
 eastern boundary of the basin. The ground here was uneven and in general low. 
 To the west and at the base of this point empties Harford Eun. In early times, 
 before the basin was dredged for this purpose, FelFs Point was the head of 
 deep water and the docking-place for vessels of deep draft. Somewhat to the 
 east of the center of the northern shore of the basin, Jones Falls discharges. 
 To the west of its mouth were the docks and piers for vessels of lighter draft. 
 Directly opposite Fort McHenry and over 2 miles southeast of FelFs Point is 
 Lazaretto Point, long the seat of the quarantine station and of the old lazaretto 
 for the reception of goods from quarantined vessels. 
 
 To the east and west of the city, along the fall line, extends a narrow and 
 comparatively low ridge containing iron ore, wherefrom the ridge derived its 
 name, Mine Banks. To the south of the Mine Banks and on each side of the 
 Patapsco Eiver the land is in general relatively flat, with numerous inlets and 
 small streams and was formerly marked by swamps and ponds. From the 
 earliest records until recent years this region was a hotbed of malaria, and in it 
 the city’s quarantine hospitals and pest houses have always been situated. 
 
PHYSICAL AND SOCIOLOGICAL DATA CONCERNING BALTIMORE 
 
 3 
 
 SETTLEMENT AND GROWTH IN AREA. 
 
 In 1729, on petition of the inhabitants of Baltimore County, the General 
 Assembly of Maryland provided for the erection of a town upon the Patapsco 
 Piver. In consequence, in September 1730, 60 acres of land, situated just north 
 of Northwestern Branch of the Patapsco River, purchased of Charles and 
 Daniel Carroll, was divided by commissioners into 60 lots of nearly equal size, 
 with the necessary streets, lanes, and alleys, and named Baltimore Town. It will 
 be noted from map 1 that the original town was irregular in outline. The basin, 
 since considerably narrowed at this point by fillings, formed part of its south¬ 
 ern boundary. On the north side the town was limited by the first considerable 
 range of hills. To the east were the marshy lowlands bordering the mouth of 
 Jones Falls. Only one street led to the water and the primitive docks. Through 
 the center of the town from east to west ran the principal thoroughfare, known 
 as Market Street, which was in reality the road connecting Philadelphia with 
 the southern colonies. The avowed reason for establishing this town was the 
 necessity for an additional port to serve the surrounding territory, which was 
 fast becoming an important farming country. Until 1780 the port of Baltimore 
 Town was subsidiary to Annapolis. 
 
 In 1732, also pursuant to act of the General Assembly, Jones Town (see 
 map 1) was erected on the east side of Jones Falls and northeast of Baltimore 
 Town. It consisted of 20 lots of approximately one-half acre each. Jones Town 
 was united with Baltimore Town in 1745. As these original settlements grew, 
 more land was incorporated, drained, and built upon on both sides of Jones 
 Falls to the basin. 
 
 As early as 1730, William Fell, a shipwright, had settled on the point bear¬ 
 ing his name. With the expansion of commerce and shipbuilding, the region 
 about Fell’s Point was rapidly built up, and in 1781 it, too, was legally joined to 
 Baltimore Town. 
 
 By act of the Legislature, Baltimore Town became Baltimore City on De¬ 
 cember 31, 1796. It will be observed on map 1 that by 1801, when the popu¬ 
 lation numbered about 27,000, extensive changes in the physical characters of 
 the situation has been made. Jones Falls in its lower part had been canalized 
 with masonry walls and the marshes on each side of it and about the north and 
 west sides of the basin filled in and built upon. Extensive docks lined the 
 north and west sides of the basin and Fell’s Point. The main streets, with few 
 exceptions, ran directly north and south and east and west, and were laid out 
 with great regularity. This same regularity, with ample width for most streets, 
 imposed by the early surveyors, has persisted throughout the city’s history. The 
 tendency to cling to the water-front and to expand easterly and westerly rather 
 than to the north was a striking feature of the town and early city. This has 
 been overcome slowly under the influence of railroads and modern rapid transit. 
 
 In 1816, by annexation of territory to the east, west, and north, the corporate 
 limits were considerably increased. The city now included 13.2 square miles. 
 These limits remained fixed until the annexation of 1888, when 18.45 square 
 miles were added. By the annexation of 1919, the city lines were again con¬ 
 siderably extended. With this the corporate limits embraced 91.93 square miles. 
 With each annexation there was included a fringe of closely built-up areas, im- 
 
4 PUBLIC HEALTH ADMINISTRATION - , ETC., IN BALTIMORE 
 
 mediately contiguous to the old city lines, and extensive outlying areas of 
 village and rural territory, all containing manufacturing and other industries, 
 chiefly located along the streams and the harbor. 
 
 FACTORS DETERMINING THE EXPANSION IN WEALTH 
 AND COMMERCIAL IMPORTANCE. 
 
 The birth, growth, wealth, and civic history of Baltimore are intimately cor¬ 
 related with water-borne trade. In the minds of the petitioners for the erection 
 of Baltimore Town, the harbor for the convenient loading of tobacco, then the 
 principal staple of export and medium of exchange for manufactured goods 
 needed, was the chief consideration. The first public building was a tobacco 
 warehouse situated near the basin. A second factor of prime importance was 
 its situation on the Philadelphia Road, the direct land route between New 
 England, New York, and Philadelphia and the rich southern colonies. To 
 the land side, striking natural advantages were convenient deposits of copper 
 and iron ore within easy reach, abundant timber of great variety and of fine 
 quality from nearby forests, the water-power of Jones and Gwynn’s Falls and 
 of the Patapsco River and other streams, fine clay for brickmaking within her 
 gates, marble and other building stone at her doors, and the rich agricultural 
 lands of first the Piedmont and later of the Ohio Valley for grains, flax, meats, 
 hides, vegetables and similar products. Tobacco from the tide-water counties, 
 and fish from the Chesapeake Bay could be readily shipped in vessels. 
 
 These great natural advantages were cultivated and later exploited by a 
 rapidly growing band of adventurers drawn first from Maryland, then from the 
 British Isles, and particularly from the north of Ireland and Scotland, and 
 later from Virginia, North Carolina, New England, New York, and Penn¬ 
 sylvania. Of considerable importance were two groups of French extraction, 
 the Acadians who were forcibly transplanted by the British in 1756 and 
 the San Domingan refugees who arrived in 1793. The arrival, after the middle 
 of the eighteenth century, of a few people of German extraction, largely from 
 Pennsylvania, who were trained in the arts of spinning and weaving and in 
 saddle and harness making, was opportune. 
 
 Despite the natural advantages and the adventurous and determined popu¬ 
 lation, the early growth and progress of Baltimore would not have been pos¬ 
 sible without another gift—a genius for innovation and adaptation in transpor¬ 
 tation on both water and land. The genius of Baltimore shipbuilders developed 
 the famous Baltimore clipper, the fastest cargo and fighting wind-driven vessel 
 known to history. On the same model they built, first the small schooner and 
 later the larger square-rigged vessel, the bark, the brig, and their modifications, 
 and the full-rigged ship. These two types differed only in size and rig, and 
 their startling success was due to two characteristics—the design of the hull 
 and the tall masts carrying an unusual area of sail. This model, “ full forward 
 and off aft ” or “ catfish head and mackerel tail,” was broader and higher in 
 the bows than in the stem, and further characterized by “ a great dead-rise at 
 her mid-ship section, long, easy, convex water-lines, low free-board and raking 
 stern, stern-post, and masts.” This design, variously ascribed to the Chesapeake 
 water-fowl, - to Capt. John Smith’s pinnace, and to the French lugger, speci¬ 
 mens of which visited the Chesapeake during the Revolution, marked a great 
 
X 
 
 MAP 2. 
 
 (From Dr. Th. H. Buckler.) 
 
MAP 2 
 
 
 W rn 'Vt/he# StaveyvrfialtzmeTrv 
 
 (From Dr. Th. H. Buckler.) 
 
PHYSICAL AND SOCIOLOGICAL DATA CONCERNING BALTIMORE 5 
 
 advance over the ungainly hulks of the British navy and merchant marine. 
 Owing to the superiority of model, excess of sail, and the unusual skill and 
 daring of their skippers and crews, these vessels outsailed and outmanoeuvred 
 everything afloat and laughed at blockading fleets in both home and foreign 
 waters. As privateers they were particularly well adapted, and great wealth 
 was brought to Baltimore in prizes and prize-money during the wars with 
 Britain. During the wars of the French Revolution and of Napoleon, the en¬ 
 terprising Baltimore merchants captured with these vessels a large part of the 
 world’s shipping trade. They were especially active in the West Indian, South 
 American, Mediterranean, Spanish, North Sea, and Baltic ports. Some reached 
 out to the Orient. The clipper-ship era lasted until the opening of the Suez 
 Canal in 1869. This ship, which sacrificed cargo capacity to speed, was espe¬ 
 cially serviceable in time of war, for perishable and manufactured goods of 
 small bulk and for passengers. It finally gave way to the coasting schooner and 
 the steamship, and had almost disappeared by 1890. One of the most famous, 
 the John Gilpin, on a voyage to the Orient and to South America, sailed some 
 34,920 miles at the average rate of 183 miles a day. 
 
 With the settlement and development of the country in her rear, first nearby 
 in Maryland, and then at a distance to and over the Alleghenies, land transpor¬ 
 tation became a matter of great importance to the growing city and its tribu¬ 
 tary country. For a time, rough wagon-roads and pack-trails sufficed. Late in 
 the eighteenth and early in the nineteenth centuries the construction of wide 
 turnpikes to strategic centers was begun. Thus, the Harford, York, Reister- 
 town, Frederick, Washington, Philadelphia, and other roads were gradually con¬ 
 verted into broad highways, with solid foundations and coverings, capable of 
 supporting the huge u Conestoga 99 wagons, carrying from 6,000 to 10,000 
 pounds and drawn by teams of 6 to 8 horses or mules. 
 
 Of great significance in this connection was the opening in 1818 of the Na¬ 
 tional Pike from Cumberland, Maryland, running over the mountains to the 
 Ohio River. This national thoroughfare was later extended to Indiana, Illinois, 
 and Missouri, and, until the passage of the railroads beyond the Allegheny 
 Mountains in 1852, was the highway from East to West for the mails and most 
 of the travel and traffic. The improved State highway from Baltimore to Cum¬ 
 berland was completed in time for Baltimore to take full advantage of the 
 National Pike to hold and to extend her trade with the West, for which she was 
 the natural market. As early as 1819 a stage route was established to Pitts¬ 
 burgh and Wheeling. 
 
 By 1823, however, her supremacy was threatened on the one hand by Phila¬ 
 delphia, over the highways built through Pennsylvania, and on the other by 
 New York, over the newly opened Erie Canal. Somewhat later, steamers from 
 New Orleans invaded the Ohio River. But Baltimore merchants arose to the 
 occasion and planned and executed their second great contribution to trans¬ 
 portation, this time by land. Casting aside the first considered plan, canals 
 from the Susquehanna and the Potomac rivers, they decided to construct a 
 railroad from Baltimore by the most direct route to some point on the Ohio 
 River. This decision, arrived at in 1827, resulted in the Baltimore and Ohio 
 Railroad, the first railroad for general purposes. Most of the early problems of 
 track and motive power were solved by Baltimoreans. The new road was open 
 to Point of Rocks, 72 miles, in 1832, to Harpers Ferry in 1834, to Cumberland 
 
6 
 
 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 in 1842, and to Wheeling in 1852. Connection with other roads opened the 
 Baltimore and Ohio service to Cincinnati and St. Louis in 1857. Meanwhile, 
 at Harper’s Ferry, connections were made with short but important railroads 
 leading into the Valley of Virginia. The extension to Cumberland made avail¬ 
 able extensive fields of cheap steam coal to Baltimore. 
 
 Other railroads soon followed. The Baltimore and Susquehanna, begun in 
 1829, the Philadelphia, Wilmington and Baltimore and the Baltimore and 
 Potomac started about 1830, financed partly at least by Baltimore, and finally 
 absorbed into the Pennsylvania Railroad system, connected Baltimore by rail 
 with Philadelphia and New York, Pittsburgh and the South. The Western 
 Maryland, running more centrally through the State than the others, was in¬ 
 augurated in 1852. 
 
 By 1880, with the extension and consolidation of trunk lines throughout 
 the country, which connect with all the great Atlantic seaports, Baltimore had 
 lost all of her relative advantages except one—her position nearer to the West 
 and South gave shorter hauls and thereby a favorable differential in freight 
 rates. This, with highly convenient terminal facilities, and Chesapeake, coast¬ 
 wise, and foreign steamship lines, has helped to preserve her importance as a 
 port. Advantageous arrangements made early between the Baltimore and Ohio 
 Railroad and the North German Lloyd Steamship Company fostered a large 
 trade through Bremen. Of late years cargo steamship lines have been widely 
 established, but particularly with British ports. 
 
 It is not possible to follow here in detail all the shipping, manufacturing, 
 and jobbing activities of Baltimore. It was natural that in the port of export 
 and import of a rapidly growing and developing territory, wholesale jobbing 
 should become and remain an important industry, and that in connection with 
 this as well as with materials near at hand or readily obtainable, an enterprising 
 population should develop the manufacture of iron, copper, chrome, and grain 
 products; tobacco; wooden, clay, and leather ware; powder; cotton and woolen 
 goods; clothing, hats, shoes; and the like. Nor is it strange that in such a com¬ 
 munity banking should have been highly developed at an early date, and that 
 investments in transportation and manufacturing enterprises in the West and 
 South have made high returns. 
 
 Certain very distinct periods of growth and depression characterize Balti¬ 
 more’s history. Until 1776 growth was comparatively slow. The Revolution, in 
 which she played a conspicuous part by both land and sea, found Baltimore 
 a struggling shipping village and left her an embryo city of fearless and bold, 
 yet hard-headed, inhabitants, with ships, shipyards, foundries, mills, and un¬ 
 rivaled harbor, and with a rich and expanding farming community in the 
 rear. Freed from the shackles of British navigation and manufacturing laws, 
 within the next 30 years her growth in population and wealth was fabulous. Be¬ 
 tween 1790 and 1810 the population increased nearly 250 per cent. Her mer¬ 
 chants were rich, her professional men in medicine, law, and theology were 
 distinguished, her general population was prosperous, well housed, and fed, 
 and all classes were contented. With food in great variety and abundance and 
 of the best quality, to be had cheap at convenient markets, with famous beers 
 and whiskies made locally, and every facility for the importation of foreign 
 liquors, material conditions were very attractive. Life was characterized by an 
 easy and genial courtesy and hospitality. 
 
PHYSICAL AND SOCIOLOGICAL DATA CONCERNING BALTIMORE 7 
 
 During the embargoes of the years just preceding 1812 and the period of 
 this war, when the Chesapeake was occupied by the British fleet, but especially 
 as the result of the succeeding general financial collapse and the consequent de¬ 
 cline in commerce and industry, Baltimore suffered severely. It is recorded that 
 in 1819, 20,000 people were out of employment. From 1825 to the outbreak of 
 the Civil War in 1861, Baltimore prospered in the main. During this period 
 crowds of immigrants, mainly from Ireland and Germany, entered at the port, 
 and many settled in the city. 
 
 The city was hard hit by the Civil War, for coastwise and foreign trade was 
 restricted, southern trade was interdicted, and trade with the West was par¬ 
 alyzed. During much of this period the city was under military rule and oc¬ 
 cupied by Federal troops, against whom a large and influential portion of the 
 population was hostile. Recovery was slow and not until after 1880 was the 
 comer turned. Since 1890 great advances have been made in trade and in 
 wealth from many sources. A great fire in 1904 destroyed a large portion of 
 the business section. In connection with reconstruction, which was soon com¬ 
 pleted, extensive improvements to the docks and piers of the basin were 
 carried out. 
 
 FORMS OF GOVERNMENT. 
 
 Baltimore Town was governed by commissioners, sometimes appointed by 
 State authority and sometimes elected on a restricted franchise. With few ex¬ 
 ceptions, the laws under which the town was governed were passed by the 
 Colonial Assembly or by the Legislature of the State. Granted a charter in 
 1796, Baltimore was incorporated as a city January 1, 1797, under the title of 
 the Mayor and City Council of Baltimore City. Since this date, but with 
 several more liberal charters granted at various times, the government has been 
 carried on by a mayor, a bicameral city council, a judiciary, and a local mag¬ 
 istracy. For civic purposes, the political subdivisions are wards. For nearly half 
 a century the control of the police force has been in the hands of commissioners 
 appointed by the governor of the State. Since the charter of 1900, the re¬ 
 sponsibility of the city government has been concentrated in the hands of the 
 mayor and the board of estimates, consisting of the mayor and the heads of 
 departments, who are, with several important exceptions, appointed by the 
 mayor, and subject to confirmation by the council. The schools, the park sys¬ 
 tem, the jail, the harbor, the city charities, and the sinking fund are conducted 
 by special boards composed of members appointed by the mayor for definite and 
 overlapping terms. Membership on these boards is a mark of distinction and 
 members serve without salary. Members of commissions for various other pur¬ 
 poses receive salaries. The board of estimates holds the purse strings and, to¬ 
 gether with the mayor, is the real power. On the whole this system has worked 
 well and in many departments of the city government has given reasonably ef¬ 
 ficient sendee. 
 
 METEOROLOGY. 
 
 The climate of Baltimore is exceptionally fine, with an abundance of sun¬ 
 shine and rain and a comparatively low relative humidity. As a rule, severe 
 storms are infrequent, prolonged droughts are rare, and extreme changes in 
 
8 
 
 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 temperature develop gradually. These characteristics are due in part to the tem¬ 
 pering influence of the Chesapeake Bay and in part to the fact that of the three 
 great transcontinental storm areas, two pass well to the north, while the one 
 following the southern course is moderated in its passage over the Southern 
 States before it reaches the city. 
 
 The annual averages for temperature, precipitation, and relative humidity 
 are 55.5° F., 43.18 inches, and 69 per cent, respectively. As on an average, the 
 sun shines some portion of the day on 321 days in the year, gloomy weather is of 
 rare occurrence. However, days with 100 per cent sunshine are uncommon at 
 any season of the year, for on typical days the sky is partly covered with clouds. 
 In winter the sunshine is 53 per cent of the possible amount and the relative 
 humidity is only about 70 per cent. While high winds are rare, except in con¬ 
 nection with occasional storms, the air in both summer and winter is usually in 
 gentle motion. At all seasons, in association with calm or light winds from the 
 direction of the water, fogs occur. They are rarely dense, and are usually of 
 short duration. 
 
 The temperature is mild in winter, moderate in spring and autumn, and 
 warm in summer. In table 1, compiled from data furnished by the local 
 
 Table 1.— Average monthly temperatures in degrees Fahrenheit and the average pre¬ 
 cipitation in inches for the period 1871-1920 and relative humidity for the period 
 1888-1921, inclusive. 
 
 Month. 
 
 Temp. 
 
 Precip¬ 
 
 itation. 
 
 Relative 
 humidity at 
 
 8 a.m., 12 noon, 
 and 8 p. m. 
 
 Month. 
 
 Temp. 
 
 Precip¬ 
 
 itation. 
 
 Relative 
 humidity at 
 
 8 a.m., 12 noon, 
 and 8 p. m. 
 
 Jan. 
 
 34. 
 
 3.22 
 
 p. ct. 
 
 71 
 
 July . 
 
 77.4 
 
 4.82 
 
 • p. ct. 
 
 69 
 
 Feb. 
 
 35.4 
 
 3.51 
 
 68 
 
 Aug. 
 
 75.5 
 
 4.21 
 
 72 
 
 Mar. 
 
 42.3 
 
 3.88 
 
 66 
 
 Sept. 
 
 68.5 
 
 3.85 
 
 74 
 
 Apr. 
 
 53.6 
 
 3.27 
 
 62 
 
 Oct. 
 
 58.2 
 
 3.02 
 
 71 
 
 May . 
 
 64.4 
 
 3.56 
 
 66 
 
 Nov. 
 
 46.3 
 
 2.92 
 
 69 
 
 June . 
 
 72.7 
 
 3.84 
 
 68 
 
 Dec. 
 
 37.2 
 
 3.08 
 
 70 
 
 Average annual: Temperature 55.5° F. Precipitation 43.18 inches. Humidity 69%. 
 
 office of the United States Weather Bureau, are given the average temperature, 
 precipitation, and humidity by months. It will be noted that while January is 
 the month of lowest and July the month of the highest temperature, the dif¬ 
 ference between the average monthly temperatures of December, January, and 
 February and between those of June, July, and August, is comparatively slight. 
 The average temperature is above 60° F. between 'May and September, in¬ 
 clusive, and below this level during the remainder of the year. Excessively high 
 temperatures are occasionally recorded in both May and October. On the whole 
 the ascent of the temperature from the low point in January to the peak in 
 July, and the descent through the rest of the year, follow rather regular gra¬ 
 dients. 
 
 The curve of the rainfall by months is not so regular. During February and 
 March the rainfall increases in amount decidedly over the level for January, 
 falls significantly in April, and then rises gradually to its peak in July, the hot¬ 
 test month. By September the rainfall has decreased to the level of June, and 
 
PHYSICAL AND SOCIOLOGICAL DATA CONCERNING BALTIMORE 9 
 
 during October, November, and December, the driest months of the year, the 
 monthly rainfall varies hardly at all. Measured in inches by season, the rain¬ 
 fall averages 3, 3.53, 3.55, and 4.25, respectively, for each month of the fall, 
 winter, spring, and summer. Thus it appears that the monthly rainfall is about 
 the same in winter and spring, but in the summer months it is much higher and 
 in the fall months much lower, than in the rest of the year. 
 
 Humidity is lowest in April and highest in September. In July, the month 
 of the highest temperature and rainfall, and in November, a cool month with 
 the smallest rainfall of the year, humidity stands at the level of its average for 
 the year. From 71 in January it declines progressively during February and 
 March to 62 in April. Over the succeeding five months it rises steadily to 74 
 in September and remains relatively high, 71, 69, and 70, in October, Novem¬ 
 ber, and December, respectively. 
 
 Data concerning direction of the wind are given in table 2. For the year as 
 
 Table 2. —Direction of the wind at Baltimore hy seasons of the year, according to per¬ 
 centages based upon hourly observations and averaged for 11 years. (U. S. Weather 
 Bureau.) 
 
 Season. 
 
 * 
 
 NW. 
 
 w 
 
 fc 
 
 GO 
 
 GO 
 
 w 
 
 GO 
 
 w 
 
 £ 
 
 ta 
 
 is 
 
 & 
 
 & 
 
 w 
 
 CO 
 
 •a 
 
 GO 
 
 GO 
 
 Off land. 
 
 Off water. 
 
 SW., W., NW., 
 N., NE., & E. 
 
 S. & SE. 
 
 Winter .... 
 
 16 
 
 18 
 
 11 
 
 12 
 
 20 
 
 9 
 
 5 
 
 9 
 
 45 
 
 41 
 
 72 
 
 28 
 
 Spring .... 
 
 15 
 
 18 
 
 11 
 
 14 
 
 15 
 
 13 
 
 7 
 
 7 
 
 44 
 
 42 
 
 73 
 
 27 
 
 Summer ... 
 
 14 
 
 12 
 
 10 
 
 21 
 
 18 
 
 13 
 
 7 
 
 5 
 
 36 
 
 52 
 
 66 
 
 34 
 
 Autumn ... 
 
 16 
 
 16 
 
 10 
 
 15 
 
 17 
 
 11 
 
 7 
 
 8 
 
 42 
 
 43 
 
 74 
 
 26 
 
 Year . 
 
 15 
 
 16 
 
 10 
 
 16 
 
 18 
 
 12 
 
 6 
 
 7 
 
 41 
 
 46 
 
 72 
 
 28 
 
 a whole, the wind blows from the northern segment for 41 per cent and from 
 the southern segment 46 per cent of the time. During the remaining 13 per 
 cent of the time due east and due west winds are almost equal in frequency. In 
 winter, spring, and autumn, northerly and due westerly winds occur with 
 greater frequency than do southerly and due easterly winds. In the summer 
 months conditions are reversed, and the wind blows from a generally southerly 
 direction for 52 per cent and from the northerly segment for only 36 per cent 
 of the time, and decidedly less frequently from due west than from due east. 
 These differences of wind direction in these two seasons are owing very largely 
 to the higher percentage of due south winds and a lower percentage of due 
 north, northwest and west winds in summer as compared with winter. This is 
 a point of considerable importance, for as a general rule winds from the north¬ 
 erly segment are associated with cold or relatively cool weather and those from 
 the south with warm or temperate weather. There is comparatively little sea¬ 
 sonal variation in the frequency of northeast winds, which are often associated 
 with rain at all seasons. The last two columns of the table show the occurrence 
 of winds in relation to the river and Chesapeake Bay near the city. It will be 
 observed that in summer the percentage of frequency of land winds falls and 
 the percentage of frequency of winds from over the water rises decidedly as com¬ 
 pared with what obtains at other seasons. 
 
10 
 
 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 The average hourly wind velocity (table 3) is 6.4 miles. From June to De¬ 
 cember the wind velocity is below and from January to May is above the aver¬ 
 age for the year. The highest velocities occur in February, March, and April, 
 and the lowest in June, July, and August. 
 
 The mean annual barometric pressure (table 3) is 30.05 inches. Though the 
 extremes are not great the highest monthly pressures occur in the colder months 
 and the lowest in the warmer months of the year. 
 
 Table 3. —Average hourly wind velocity (51 years) in miles, and the mean sea-level 
 barometric pressure (48 years) in inches. (U. S. Weather Bureau.) 
 
 Month. 
 
 Wind 
 
 velocity. 
 
 Barometric 
 
 pressure. 
 
 Month. 
 
 Wind 
 
 velocity. 
 
 Barometric 
 
 pressure. 
 
 Jan. 
 
 6.5 
 
 30.13 
 
 July . 
 
 5.9 
 
 29.98 
 
 Feb. 
 
 7.1 
 
 30.10 
 
 Aug. 
 
 5.4 
 
 30.01 
 
 Mar. 
 
 7.5 
 
 30.04 
 
 Sept. 
 
 5.6 
 
 30.08 
 
 Apr. 
 
 7.4 
 
 30.00 
 
 Oct. 
 
 6.0 
 
 30.11 
 
 May . 
 
 6.6 
 
 29.98 
 
 Nov. 
 
 6.2 
 
 30.10 
 
 June . 
 
 6.2 
 
 29.99 
 
 Dec. 
 
 6.3 
 
 30.12 
 
 These composite pictures of the general meteorological phenomena give, after 
 all, an incomplete idea of the actual conditions, particularly in summer. The 
 hills which surround the city on parts of three sides and the nearby large 
 bodies of water to the south temper the winter in the city. The hills and valleys 
 of the city itself are in general favorable for the circulation of air in the 
 summer. In the main, the weather of spring, autumn, most of the winter, and 
 part of the summer is ideal. Periods of two to three days to a week or two in 
 summer characterized by an excess of heat associated with a high degree of 
 humidity are not of infrequent occurrence. In these periods official afternoon 
 temperatures of over 90° are commonly recorded, and in most of the built-up 
 and in all of the low-lying parts of the city, particularly in the business and 
 manufacturing sections, the temperature registers much higher levels. On these 
 * occasions, when, in the absence of breeze, the pavements and brick houses re¬ 
 tain at night the heat absorbed during the day, in many parts of the city the 
 atmosphere is stifling. Under these conditions, while relatively few deaths are 
 ascribed definitely to heat-stroke, the death-rate from various causes, particu¬ 
 larly among infants and the aged, rises significantly. Mortality from causes 
 peculiar to early infancy and from gastro-intestinal affections of individuals 
 under 2 years of age commonly reach the highest level in these periods. On 
 the other hand, the heat of summer is usually mitigated by clouds, refreshing 
 breezes, by day and night, and frequent thunder-showers. In the higher portions 
 of the city, and particularly in the openly built sections in the hilly districts, 
 excessively oppressive heat throughout the 24 hours is rare. The comparatively 
 mild and short winter season exercises an important effect upon employment in 
 all out-of-door work and especially in construction activities. There are 
 relatively few days when workers are debarred from plying their trades, and on 
 this account seasonal lay offs are of less importance than in less genial climates. 
 
Chapter II. 
 
 Physicians and medical education; Hospitals and dispensaries; Chari¬ 
 ties; Dwellings; Schools. 
 
 PHYSICIANS. 
 
 Medicine and medical men have played an unusually prominent part in the 
 life and development of Baltimore. Two of the five commissioners appointed 
 to lay out the town were physicians, Drs. George Buchanan and George Walker. 
 Three years later, the latter assisted in the founding of Jones Town, across 
 Jones Falls, afterwards united with Baltimore Town. The four physicians 
 in practice in 1756 included Drs. Henry Stevenson and Charles Wiessenthal, the 
 first distinguished later as one of the foremost inoculators in America against 
 smallpox, and the latter, universally revered as the Sydenham of Baltimore 
 Town. From figures given by Quinan, the number of physicians resident in 
 early Baltimore and their proportion in the population in different years were 
 as follows: 1776, 19, or 1:355; 1782, 23, or 1:347; 1790, 30, or 1:450; 
 1799, 34, or 1: 617; 1810, 46, or 1: 1,012. 
 
 In connection with the rapid growth of the town and State in wealth and 
 population during the last decade of the eighteenth century, there was an 
 extensive invasion of medical quacks. In order to control these, a movement 
 begun by Dr. Charles Wiessenthal of Baltimore and Dr. John Hall of Frederick 
 resulted in the establishment in Baltimore of a medical society in 1785, and, 
 in 1799, the Medical and Chirurgical Faculty of Maryland was granted the 
 right by charter from the legislature to license candidates for medical prac¬ 
 tice after “ a full examination before the board of examiners,” or “ in lieu 
 thereof presenting a satisfactory diploma.” The 101 incorporators, from all 
 parts of the State, represented the best elements of the State and town and in¬ 
 cluded men trained in the medical schools of Leyden, Paris, London, Oxford, 
 Edinburgh, Glasgow, Aberdeen, and Dublin; but as late as 1807, of the 241 
 members of the faculty, only 17 per cent had medical degrees. Among the 
 Baltimore physicians at the opening of the nineteenth century were men with 
 names then and ever since of the highest standing in the city and State. The 
 Medical and Chirurgical Faculty, in order of its foundation the seventh State 
 medical society, has been closely identified throughout its history with medical 
 education and public-health measures. 
 
 The faculty indorsed vaccination against smallpox in 1802, appointed com¬ 
 mittees of investigation and advice to the health department during the early 
 yellow-fever epidemics, especially that of 1819, advised the mayor and the city 
 council in regard to the health ordinances in 1820 and in other years, urged 
 the appointment of public vaccinators in 1821 and the establishment of a State 
 vaccine agency in 1864, and has taken an active part in securing acts of the 
 legislature in regard to public health. The faculty did not long retain com¬ 
 plete control over medical practice, for, under pressure of medical charlatanism 
 2 
 
 11 
 
12 PUBLIC HEALTH ADMINISTRATION, ETC., 1ST BALTIMORE 
 
 in the rapidly growing community, the powers of licensure after examination 
 were withdrawn by the legislature, not to be regranted until 1892. Thus, for 
 many years its power in this direction was limited to the influence of the high 
 standard of medical ethics which it set up and consistently maintained. Bal¬ 
 timore has had its quota of societies and clubs devoted to the encouragement of 
 general medicine, surgery, obstetrics and gynecology, pathology, and various 
 other departments of medicine, many of them associated directly or indirectly 
 with the Medical and Chirurgical Faculty. However, as it will appear later, the 
 leading Baltimore physicians have ever been disposed to do their own think¬ 
 ing and to be guided by their own observations. In the later years of the 
 eighteenth and in the earlier years of the nineteenth centuries they were in¬ 
 clined to repudiate the domination of contemporary British in medicine as in 
 politics. Rush, the outstanding figure of American medicine in his day, seems 
 to have carried but little weight with them. In later years Philadelphia, New 
 York, and Boston were heard with respect. By the rising French school of the 
 first half of the nineteenth century, and in particular by Laennec, Andral, 
 Louis, Bretonneau, Rielliez, Barthez, Trousseau, and Charcot, they were slowly 
 but markedly influenced. Not until after the intensive development of patho¬ 
 logical anatomy and of bacteriology in Germany were Baltimore physicians 
 much affected by the medical teachings of that country. 
 
 MEDICAL EDUCATION. 
 
 The first medical teaching of a formal kind in Baltimore was given during 
 the winter of 1789-90 by Dr. George Buchanan in diseases of women and chil¬ 
 dren and by Dr. Andrew Wiessenthal in anatomy, physiology, pathology, and 
 operative surgery. The next year chemistry and materia medica were added 
 to the curriculum of Dr. Wiessenthal’s school. A program was issued, during 
 the ensuing winter, of a medical faculty, consisting of Dr. Andrew Wiessenthal, 
 anatomy; Dr. George Brown, practice of medicine; Dr. Lyde Goodwin, sur¬ 
 gery; Dr. S. Y. Coale, chemistry and materia medica; and Dr. George Buch¬ 
 anan, obstetrics. Drs. John B. Davidge, James Cocke, and John Shaw soon 
 afterwards offered courses of lectures. 
 
 An important part of the original plan of the organizers of the Medical and 
 Chirurgical Faculty was a school of medicine under the supervision of the or¬ 
 ganized profession, and in his address in 1801, the president of the faculty 
 urged the adoption of a plan to organize such a school in Baltimore. In 1803, 
 Dr. John B. Davidge, with Dr. George Brown and others, was appointed to con¬ 
 sider a plan for the proposed medical school, but it was not until December 18, 
 1807, that the College of Medicine of Maryland, the fourth in the United States, 
 was incorporated, with six professors. The cornerstone of the new college 
 building, a handsome and, for those days, commodious structure, was laid in 
 1811, and in 1812 the college became the medical department of the University 
 of Maryland. Among the early professors, John B. Davidge and Nathaniel 
 Potter stand out as erudite and forceful men, who by their teachings and writ¬ 
 ings profoundly influenced the attitude of their contemporaries on questions 
 of public health. The school, under the control of regents, was conducted with 
 dignity and due sense of responsibility to the profession and to the community. 
 An important reason for the great reputation it finally won was the fact that 
 
PHYSICAL AND SOCIOLOGICAL DATA CONCERNING BALTIMORE 13 
 
 the authorities did not hesitate to go out of town for teachers. In 1820, Gran¬ 
 ville Sharp Patterson and, in 1827, Nathan R. Smith were called to fill the 
 chair of surgery. Elisha Bartlett was called to succeed Potter as professor of 
 medicine in 1844, and he, in his turn, was succeeded by William Power, who, 
 though a native of Baltimore, had spent three years with Louis in Paris. Until 
 about 1890 this school stood among the strongest medical schools of the country 
 in strength of the faculty and methods of teaching, and it fell to a secondary 
 place only when it failed to establish strongly manned and well-equipped lab¬ 
 oratories of anatomy, physiology, and pathology. Besides the Baltimore In¬ 
 firmary, it had abundant clinical material at other hospitals. 
 
 In 1827, though there was no need for it, an ambitious group of medical 
 men, led by Horatio G. Jameson, a man of force and talent, established The 
 Washington Medical College, as the medical department of Washington Col¬ 
 lege, Pennsylvania. This school, leading a precarious existence for many 
 years, was succeeded by a proprietary school, The College of Physicians and Sur¬ 
 geons, at which some able men gave lectures and developed ward and laboratory 
 teaching to a somewhat higher degree than at the University of Maryland. It 
 used the clinical material of Mercy and other hospitals. 
 
 Later (1882), a second proprietary school, The Baltimore Medical College, 
 was founded by another group of ambitious men, for whom no positions offered 
 in the other two schools. With more modern buildings and stressing laboratory 
 teaching, perhaps more than its rivals, this school drew a large number of 
 students. 
 
 Lacking endowments, without reputation in medical research, unable to 
 exert those other qualities that draw gold to the support of medical education, 
 and their receipts cut by the decline in the number of students—due to the 
 higher entrance, teaching, and licensure requirements demanded by the State 
 examining boards, all three of these schools, about 1910, were not only unable to 
 advance, but found their existence precarious. First the Baltimore Medical 
 College and then the College of Physicians and Surgeons fused with the older 
 school. 
 
 For some years a woman’s medical college, established in 1882, led an uncer¬ 
 tain life and perished because means were not obtainable to continue a credit¬ 
 able existence. 
 
 Between 1870 and 1885 there arose several obscure medical schools with pre¬ 
 tentious names, all of them with the most primitive excuses for laboratory and 
 hospital facilities. 
 
 All of these schools, except the University of Maryland, were founded by 
 physicians ambitious for fees, but above all for the professorial title and con¬ 
 sulting practice, and throughout their existence they were proprietary. The 
 university, a legitimate child of the State, was established by the medical pro¬ 
 fession to fill a real need in medical education and was placed under the gov¬ 
 ernment of a board of regents, chosen, at least at first, from and by the Medical 
 and Chirurgical Faculty. For the first 70 years of its existence, in its stand¬ 
 ards of ethics, teaching, and examination, it reflected truthfully the ideals of 
 the best and brightest of the profession of the State. Since 1895 in teaching it 
 has not, in a relative sense, maintained this position. The two other leading 
 schools and the Woman’s Medical College had on their faculties during their 
 whole existence many men of the highest standing in the community and of 
 
14 
 
 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 considerable professional attainment, and especially during the past 20 years, 
 often at least, the equals in ability of the holders of their respective chairs in 
 the University of Maryland. While, as a general rule, all these schools drew 
 the bulk of their students from other States, and most of the better class of 
 Maryland students attended the university, a not inconsiderable number of 
 non-resident graduates of all of them settled in Baltimore, and many Balti¬ 
 more students of deficient education graduated from the lowest type of pro¬ 
 prietary schools—the diploma mills of the worst type. As a consequence of the 
 relatively low standards of the four schools of the better type and of the de¬ 
 based standards of those of the poorest type, between 1875 and 1905, the medi¬ 
 cal profession was recruited by large numbers of relatively defective, ranging 
 from bright men of college education and trained in the fundamental sciences 
 but handicapped by poor facilities and opportunities offered by the better 
 schools, through the gamut to the mentally slow and dull, whose opportunities 
 in both preliminary and medical education were scandalously deficient. Medi¬ 
 cal practitioners of the same grades, botli residents and non-residents, who had 
 attended schools of all orders elsewhere, some of them graduates of foreign 
 universities, completed the list. As a result of all these factors, there was added 
 to the Baltimore profession, during the period of greatest activity of the pro¬ 
 prietary schools, a considerable group of physicians deficient not only in the 
 knowledge of physiology and pathology and the natural history of disease, but 
 in modern methods of diagnosis and particularly in the principles underlying 
 protective vaccination and serum therapy, defects which have left them a prey 
 to the guile of pseudo-scientific manufacturers of drugs and biological products. 
 One of the most striking evils of medical education in Baltimore during this 
 period was a lack of practical teaching in obstetrics and in infant and child 
 feeding. 
 
 Throughout its whole history from 1780 to at least 1890, except during a 
 few years when the Medical and Chirurgical Faculty had control of medical 
 licensure, the city had its share of advertising quacks and other medical char¬ 
 latans. That all these untoward factors have made distinct contributions to 
 the general death-rate and to the rates for certain diseases is beyond ques¬ 
 tion. Nevertheless, it is probable that during this period until 1895 the general 
 level of medical practice in Baltimore was at least as high as that of the At¬ 
 lantic seaboard cities and much higher than that of cities to the west and south. 
 This state of affairs was due partly to a few forceful teachers in each genera¬ 
 tion, to the natural ability of those who came to the top, and to the fact that 
 on account of defects in their home teaching, many sought postgraduate in¬ 
 struction abroad. 
 
 After the founding of the Medical and Chirurgical Faculty and of the Uni¬ 
 versity of Maryland under its auspices, the most profoundly important bene¬ 
 ficial influence upon medicine in Baltimore is that of the Johns Hopkins Uni¬ 
 versity, opened in 1876, the hospital in 1889, and the medical school in 1893. 
 The influence of scientific investigation and laboratory teaching in physics 
 under Rowland, chemistry under Remsen, zoology under Brooks, and physiology 
 and histology under Martin was well established by 1880. As these men entered 
 freely into the public and social life of the community, the influence of their 
 ideas and methods and wide knowledge rapidly spread in intellectual circles, 
 
PHYSICAL AND SOCIOLOGICAL DATA CONCERNING BALTIMORE 15 
 
 of which the leading physicians formed an important part. Young men going 
 into medicine took their courses and young medical graduates sought and ob¬ 
 tained admission into their classes, particularly in chemistry and physiology 
 and histology. Here Abbott, Councilman, and Booker, as postgraduate stu¬ 
 dents, got their first training in microscopy; here also Sternberg did his early 
 work in bacteriology. 
 
 Thus, the time and the settings were ready for the advent in 1884 of Welch, 
 whose first courses were given in the biological laboratory. The brighter of 
 the younger and many even of the established physicians during the next 10 
 or 15 years enrolled themselves in the courses in bacteriology and pathological 
 anatomy offered by Welch and his associates in his pathological laboratory. 
 Fortunately, Welch's courses were also opened to those undergraduates of the 
 Johns Hopkins University who expected to study medicine. By these means, 
 interest in the fundamental sciences in Baltimore was revived and rekindled. 
 Young men entering medicine had opportunity to pursue them, and gradu¬ 
 ates in medicine as well were enabled to make up their deficiencies in physiology, 
 microscopic anatomy, micro-parasitology, pathological anatomy, and general 
 pathology. From these springs, medicine in Baltimore drank a revivifying 
 draught. By 1890, Welch's students comprised directly or indirectly the whole 
 medical profession of Baltimore, for there were few so ignorant or so fossilized 
 that they could not absorb something of knowledge so simply diffused and im¬ 
 parted by this clear-headed, impelling master, whose kindly manner reassured 
 the meek and abashed the arrogant. Whether it was the student who in the 
 laboratory was encouraged to utilize the ample material, or the experimenter, 
 to teach himself, or the physician in professional or social gatherings and 
 in visits of consultation at his home, all took away a new conception of medicine 
 and the inspiration to follow it. The most valuable service rendered at this 
 time was to the brighter young medical graduates, who threw aside the medical 
 text-books of the day and read in their stead the masters in medicine and the 
 better articles of the current literature, and, freed from the dogmas and gener¬ 
 alities of the schools and imbued with the spirit of observation, experiment, and 
 critical analysis, thought for themselves. 
 
 The next important step was the opening of the Johns Hopkins Hospital in 
 1889, when the local medical profession received a salutary shock when made 
 to realize that no one of them had so cultivated the medical sciences as to reach 
 eminence of the kind and degree that would warrant the trustees to select him 
 as head of a department of medicine, surgery, or obstetrics and gynecology. As 
 a result, quite apart from their abilities, the newcomers had a crowd of pupils 
 and voluntary assistants, eager to follow new leaders. The latter were for¬ 
 tunately chosen, and their influence upon medical and surgical research and 
 practice, both within and without Baltimore, is too well known to need elab¬ 
 oration here. Since the tracing of the effects of the Johns Hopkins institutions 
 upon the local medical profession is a part of this review, it may not be out 
 of place to point out a phase that has not received the appreciation that its im¬ 
 portance warrants. Perhaps the impression of the most fundamental impor¬ 
 tance made upon the band of Welch's pupils who followed the clinical branches 
 in the hospital—and they were chiefly the ones who were best equipped to 
 receive the new gospel—was gained in the surgical service of Halsted. There 
 
16 
 
 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 under this master in surgery, they observed the methods of the laboratory 
 constantly appealed to and applied in a manner wholly new and in a truly 
 philosophical spirit. There they saw the aseptic technique carefully built up, 
 the healing of wounds studied, and new operations developed, all under exactly 
 controlled experiments. 
 
 Osier’s influence was both deep and broad. Excelling in knowledge of the 
 natural history of disease and of the fundamental relation between pathology 
 and diagnosis, qualities that the local contemporary leaders in the profession 
 prided themselves upon, he was in addition familiar with the chemical, micro¬ 
 scopical, and bacteriological methods of diagnosis in which they were deficient. 
 With these qualifications and his great gifts of mind and character, Osier at 
 once assumed leadership and set new standards of diagnosis and of hospital 
 and dispensary organization. His critical attitude toward the value of many 
 drugs in the treatment of disease was largely responsible for winning the battle 
 for expectant treatment and a fuller realization of the importance of vis medi- 
 catrix naturae. 
 
 Kelly’s advent fell at a propitious time for obstetrics and gynecology, in 
 which both teaching and consulting practice were very largely in the hands of 
 relatively old men, who, however great had been their services in the past, 
 unlike the general surgeons, were incapable of taking full advantage of anti¬ 
 septic methods to extend the boundaries of their fields. Apt in acquiring the 
 new technique and possessed of unusual natural and acquired surgical gifts and 
 a peculiar combination of boldness and versatility of resource, he soon made 
 radical advances in gynecology and set new standards of obstetrics in Baltimore. 
 
 The School of Nursing in the Johns Hopkins Hospital exerted almost im¬ 
 mediately a beneficial effect upon nursing in the Baltimore hospitals and 
 dispensaries. 
 
 The immediate effects upon the local medical schools of the Johns Hopkins 
 Medical School upon its opening in 1893 were exerted directly in improving 
 methods and facilities for teaching and indirectly in taking away most of the 
 local medical students with college training. From this time on, it was clear 
 that the graduates of the new school with its higher standards, exact scientific 
 methods, and more ample facilities must turn out a new type of physician 
 who would in time be the leader and dominate medical thought and action, and 
 this prophecy was fulfilled in a remarkably short time. The transition was the 
 easier because of the gradual leavening process that had been in progress since 
 1880. This process was evolutionary rather than revolutionary, and, owing to 
 the good spirit of the leaders and mass of the profession, as well as of the 
 teachers in the new and in the old schools, the metamorphosis was accom¬ 
 plished, on the whole, with remarkable smoothness and lack of bitterness. As 
 a result, the profession held together without serious splits, and in the Medical 
 and Chirurgical Faculty and other societies working in harmony, it was able 
 to exert a salutary influence in improving medical practice and in securing 
 remedial legislation and improvement in administrative measures in matters 
 concerning the public health. The final result has been that in public con¬ 
 fidence and influence, the medical profession of Baltimore, which always stood 
 high, has outstripped all others. 
 
 The names of those who stand out after the lapse of time as real leaders and 
 contributors to medicine in Baltimore are: Henry Stevenson, the inoculator; 
 
PHYSICAL AND SOCIOLOGICAL DATA CONCERNING BALTIMORE 17 
 
 Charles Wiessenthal, the educated physician, patriot, and medical reformer; 
 James Smith, the vaccinator; Andrew Wiessenthal and George Buchanan, the 
 early medical teachers; John B. Davidge, author and student and the father 
 of the University of Maryland; David Meredith Reese, the student and his¬ 
 torian of yellow fever; Ashton Alexander and Thomas E. Bond, advisers in 
 public-health administration; Horatio C. Jameson, surgeon and student of 
 public health; Pierre Chatard, the great obstetrician; George Frick, the eye 
 surgeon; Nathaniel Potter, the medical philosopher and experimenter; Na¬ 
 than R. Smith, Gibson, and Halsted, the surgeons; and Elisha Bartlett, William 
 Power, Thomas H. Buckler, Charles Frick, William T. Howard, Sr., William 
 Osier, and William D. Booker, students of the natural history of disease. 
 
 HOSPITALS AND DISPENSARIES. 
 
 Institutions of this type exert both direct and indirect effects upon the mor¬ 
 bidity and mortality of a community. The beneficial influences of hospitals 
 upon morbidity in furnishing asylum for the isolation of persons with com¬ 
 municable diseases occurring in the general population may be largely counter¬ 
 balanced in improperly constructed and managed institutions by the spread of 
 communicable diseases so introduced among their own populations. There is 
 ample evidence that typhus, typhoid, and puerperal fevers, erysipelas, scarlet 
 fever, measles, diphtheria, dysentery, and small-pox have often been so spread 
 in the public and private hospitals in Baltimore. That hospitals have, at least 
 within the last 100 years, tended to lower mortality may be conceded. On 
 the other hand, hospitals, especially those widely known, with men on their 
 staffs of considerable reputation in this or that branch, notably in surgery and its 
 subdivisions, attract large numbers of non-resident sick—many poor operative 
 risks and some hopelessly ill, an uncertain proportion of whom inevitably die 
 in the city. Thus, hospitals of this class, which have been and are relatively 
 numerous in Baltimore, by adding to the number of deaths of non-residents, 
 have certainly been responsible for an increase in the gross number of deaths 
 chargeable against the city. Dispensaries, besides serving as centers for the dis¬ 
 pensation of treatment to the poor, have long been recognized as valuable aids 
 to public-health administration, because in them often the earliest cases of 
 certain communicable diseases in the community are discovered. 
 
 PUBLIC HOSPITALS. 
 
 The public hospitals of Baltimore have by their location exerted an appar¬ 
 ently favorable, though really fictitious, influence on the death-rate, both gen¬ 
 eral and specific, of Baltimore, since the deaths occurring in all of them at 
 one time or another have been credited to the places in which the institutions 
 were situated, rather than to the place from which the sick were sent. This 
 was particularly true of the infirmary or hospital wards in connection with 
 the almshouse, and the hospitals in connection with the quarantine station, all 
 of which at one time or another have been situated beyond the limits of the 
 city, and to all of which city patients with acute diseases have been sent. In 
 the earlier period of the city’s history, it is unlikely that the bodies of individ¬ 
 uals dying at the almshouse, even of non-communicable diseases, were brought 
 
18 
 
 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 to the city and buried in Potter’s Field or other cemeteries. Since the tables 
 of mortality were compiled from the reports of the sextons of cemeteries, until 
 death certificates were required in 1875, and since, even after this time in some 
 years, the large number of deaths at Bayview Asylum and Sydenham Hospital 
 were excluded from the list of city deaths, and since it has been constant prac¬ 
 tice to exclude from this list all deaths at the Quarantine Hospital, these omis¬ 
 sions are of considerable importance. The almshouse infirmaries served a double 
 function in affording hospital care to some of the indigent sick in the general 
 population, as well as to the sick among their own residents. Since the latter are 
 recruited in general from those of middle or advanced age in the general popu¬ 
 lation with a relatively short life expectancy, when the deaths among them are 
 omitted from the city bills of mortality, it amounted to withdrawing from the 
 city each year a certain number of poor risks and to subtracting the deaths 
 among them from the total deaths. 
 
 The first public hospital was opened in 1776 or 1777 as an infirmary in con¬ 
 nection with the large almshouse of Baltimore City and County, situated just 
 without the town, near the present Richmond Market. There is no record of 
 the number of beds, but the wards of the infirmary were certainly open to the 
 sick poor without as well as within the almshouse. The almshouse and its 
 infirmary were transferred to new quarters without the city limits at Calverton 
 in 1823. The infirmary continued to serve as a hospital for the city poor, and 
 it received cases of acute and chronic diseases. There was also an obstetrical 
 ward and a ward for foundlings. The city authorities often used it as a pest- 
 house. Severe outbreaks of cholera occurred there in 1832 and in 1849. A 
 vivid picture of the risks run by those sentenced to this hospital is given in the 
 following quotations from T. H. Buckler’s (11) description published in 1851 : 
 
 “ A single case of erysipelas brought to the house would often in a very short time, 
 spread the infection to all the other wards, rendering it dangerous to perform the most 
 simple operation, even that of bleeding. The slightest wound was sure to be followed 
 by erysipelas, phlebitis, and in some instances, gangrene, and all this was attributed to 
 hospital atmosphere. Was it the air of the wards alone, or other causes, which produced 
 these results? The establishment affording no facilities for isolation, it was not unusual 
 to see in the same ward, at the same time, cases of typhoid fever, erysipelas, dysentery, 
 and typhus or ship fever. And it repeatedly happened that patients admitted with pneu¬ 
 monia, pleurisy, or some other acute affection were seized, before their convalescence 
 was perfectly established with some one of these morbid poisons, which, in the weak 
 state of their systems, too often proved fatal. It is at best but poor humanity to send a 
 man to a charity hospital, to get rid of one affection, and at the same time, place him 
 under circumstances where he is very likely to contract a much more dangerous 
 malady.In 1844, and again in 1845, when the house was under the care of Pro¬ 
 
 fessor Power, of the University of Maryland, the poison of puerperal fever was so in¬ 
 tense that death was sure to ensue in the case of every lying-in woman, the attack com¬ 
 mencing usually in from 4 to 12 hours after parturition. In each of these years, some 
 8 or 10 cases consecutively proving fatal, this ward was abandoned, the women expecting 
 confinement were sent to the Washington College Hospital, and no other cases of the 
 kind were admitted for a period of 6 months. Every summer the children suffered from 
 cholera infantum, and where they escaped this disease, they were almost sure to perish 
 in the winter with pneumonia. In the whole history of the establishment there is no 
 single example of a foundling that has lived to the age of 3 years.” 
 
 A shift was made to a new and commodious plant at Bayview in 1866, the 
 mixed almshouse and hospital features being preserved. During the last 20 
 
PHYSICAL AND SOCIOLOGICAL DATA CONCERNING BALTIMORE 19 
 
 years extensive additions and improvements have been made, including a sepa¬ 
 rate general hospital for general diseases of about 150 beds for the city poor. 
 There was established also a separate tuberculosis hospital for advanced cases. 
 For many years there has been a pavilion to accommodate the insane among 
 city residents, for whom the State insane asylums did not afford room. 
 
 In 1797, the legislature authorized the erection in or near Baltimore of a 
 hospital for indigent sick and lunatics. This hospital, variously known as the 
 Public, City, or Maryland Hospital, was located without the city limits of that 
 time, on an elevated site, now occupied by the Johns Hopkins Hospital. It was 
 opened in 1800, when about one-thirckcompleted, with 130 beds. It was leased 
 in 1808 to I)rs. Colin McKenzie and James Smith for a period of 15 years, 
 and in 1814 the lease was extended on condition that the lessees would complete 
 the central building, a lunatic asylum, and an additional hospital wing. It was 
 to this hospital that yellow fever patients were sent in during the epidemics 
 between 1800 and 1819. In 1814, 234 sick and wounded soldiers were re¬ 
 ceived, after the battle around Baltimore. The courts began to commit the 
 insane to special wards of this hospital in 1807. Clinical lectures were given in 
 the hospital in 1818 by Professor Nathaniel Potter, and in 1822 by Drs. Colin 
 McKenzie and George Frick. By the annexation of 1816, this hospital came 
 within the limits of the city. 
 
 Between 1826 and 1834, additional buildings were completed, the administra¬ 
 tion of the hospital passed to the State, and admissions were limited to the in¬ 
 sane. It appears that for some years before the latter date this hospital had 
 admitted sick sailors and immigrants with certain communicable diseases. This 
 institution was finally abandoned as an insane asylum after the completion of 
 the new State Hospital for the Insane at Spring Grove in 1854, and the prop¬ 
 erty was soon afterwards purchased by Mr. Johns Hopkins, and later became the 
 site of the hospital founded by him. 
 
 The account of the quarantine hospitals will be given in connection with the 
 quarantine station. 
 
 During the cholera epidemic of 1832, the health department conducted three 
 improvised hospitals, and about 1835 it opened a small-pox hospital, which, in 
 1837, was leased to the Washington Medical University, with the provision that 
 when necessary a certain number of small-pox patients would be received at 
 a stipulated per diem charge, an arrangement held to until the opening of the 
 marine hospital of the quarantine station in 1847. 
 
 For a number of years the city has paid a small per diem charge to a num¬ 
 ber of private hospitals for the care of indigent sick, for whom no room was 
 available in the almshouse infirmary. 
 
 In 1909, Sydenham Hospital, with accommodations for 40 cases of diph¬ 
 theria, scarlet fever, measles, and chicken-pox, was opened. In 1914 it was 
 expanded to accommodate 60 patients. 
 
 PUBLIC DISPENSARIES. 
 
 The city has supported several general dispensaries for the treatment of the 
 poor. The most important of these and the dates of their foundation are: The 
 Baltimore General, 1808; the Eastern, 1818; the Western, 1847; and the 
 Southern, 1847. 
 
20 
 
 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 PRIVATE HOSPITALS. 
 
 The hospitals placed under this heading were built and conducted not by 
 the city authorities, but by chartered corporations, and their chief and in some 
 instances sole source of support has been derived from gifts and endowments 
 and fees of patients. Many have succeeded in securing appropriations from the 
 State. Most of them have received small per diem payments for indigent pa¬ 
 tients, for whom room was not available in the city-owned hospitals, and at 
 times, for some hospitals especially, this has been an important item until re¬ 
 cently. Nearly all of these hospitals throughout their history have posed as 
 charitable institutions, created and maintained primarily for the care of the 
 poor, but in most instances even cursory investigation shows that this is not 
 true. These institutions readily fall into distinct categories : 
 
 (1) There are those institutions started in connection with medical schools, 
 the primary aim in the foundation and conduct of which was clinical material 
 for teaching students, a theater for the professors, and hospital accommodations, 
 particularly private rooms, for the patients of the latter. From the start they 
 were important to the medical-professor business. The first hospital of this class, 
 the Baltimore Infirmary, was founded in connection with the University of 
 Maryland Medical School and opened in 1823 with 4 public or free wards. 
 There was a considerable enlargement in 1850 with private rooms. Later ex¬ 
 pansions have greatly increased the total accommodations for both free and 
 pay patients. This general hospital has maintained an obstetrical service for 
 many years, housed in a separate building since about 1885, and at one time 
 had a ward for acute contagious diseases, where patients from steamship com¬ 
 panies were received on contract. The second was that of Washington Medical 
 College, established in 1838 and closed with the failure of the school in 1851. 
 The small so-called City Hospital was developed by the College of Physicians 
 and Surgeons after 1878, and about 1890 it was taken in charge by a Catholic 
 sisterhood, which has been largely responsible for securing funds and for 
 elevating it into a large general hospital. However, the private rooms for pay¬ 
 ing patients of this hospital form a very large part. This hospital, with its large 
 dispensary service, was the main source of clinical material for the college whose 
 professors formed the medical and surgical staff. The Maternity, a small lying- 
 in hospital, the first separate hospital of its kind in Maryland, established in 
 1878, was conducted under the control of the same faculty. The Maryland Gen¬ 
 eral Hospital, a small hospital with a few private rooms and public wards, 
 maintaining a precarious existence, was annexed by the Baltimore Medical 
 College in 1881, and during the meteoric career of this college expanded rapidly, 
 and with the expiration of the latter in 1914, the hospital absorbed the col¬ 
 lege buildings. Here a maternity ward and a large dispensary service were 
 maintained so long as clinical material for teaching was needed. The religious 
 sect chiefly appealed to for support is the Methodist. The Woman’s Medical 
 College also conducted a small hospital. A hospital of considerable size was 
 supported for many years in connection with the Homeopathic Medical College. 
 
 (2) Hospitals built and maintained by private associations, usually more or 
 less identified with religious sects, many of them receiving larger or smaller ap¬ 
 propriations from the State either for buildings or maintenance or both, form a 
 second class. The earliest of these was the Union Protestant Infirmary, a small 
 
PHYSICAL AND SOCIOLOGICAL DATA CONCERNING BALTIMORE 21 
 
 hospital opened in 1854, with private rooms and open wards, for charity and 
 part-pay patients. Since 1895 it has undergone considerable expansion and 
 has become very largely a surgical hospital. The old college and hospital of the 
 defunct Washington Medical University were organized into a church home 
 and infirmary in 1854, under the auspices of the Protestant-Episcopal Church, 
 and in recent years, with considerable additions, it has become an important 
 hospital, with the traditional private rooms for pay patients, chiefly surgical. 
 St. Joseph's Hospital, founded in 1864, and St. Agnes Hospital, the latter until 
 recently without the city limits and organized in 1878, both supported and 
 managed by sisterhoods of the Catholic Church, have grown from small be¬ 
 ginnings into large and relatively well-equipped hospitals receiving both free 
 and pay patients. St. Joseph's Hospital conducts a large free dispensary. The 
 Franklin Square Hospital and the South Baltimore Hospital are small general 
 hospitals with open wards and private rooms. There are several special hos¬ 
 pitals for eye and ear diseases, the oldest and most prominent being the Presby¬ 
 terian Eye and Ear Hospital, founded in 1871, with 20 free beds and private 
 rooms. As its name suggests, its special support comes from the Presby¬ 
 terian Church, the religious sect of its talented first surgeon-in-chief. The 
 Woman's Hospital, founded in 1882, with an appropriation from the State, 
 for the treatment of the special diseases “ of the poor women of Maryland," 
 modeled on the famous hospital of the same name in New York, with a staff of 
 two chief and four assistant gynecologists, and governed by a board of trustees 
 and a board of lady managers, opened with only free beds. A few years later, 
 against the protests of one of the chief gynecologists, rooms for private pay 
 patients wnre added. Since 1908, this hospital has expanded into a large hos¬ 
 pital composed almost altogether of private rooms for pay patients, receiving 
 cases of all affections among women usually admitted to a general hospital; 
 and with its heterogeneous staff, it has lost completely its original features of 
 a free hospital for the treatment of women of Maryland, suffering with diseases 
 peculiar to their sex. Though the plant has been greatly enlarged, scarcely any 
 more patients of the character for which it was founded are now accommodated 
 than were a few years after it was opened. 
 
 (3) There are also hospitals built and maintained by endowments from pri¬ 
 vate individuals, founded and conducted to relieve the indigent sick and those 
 who can afford to pay, with charges to the latter, either in public or private 
 wards, graduated according to their means. The Robert Garrett Hospital for 
 Children was founded in 1888. This hospital, with modern equipment and a 
 large free dispensary service, accommodates 30 children with medical and sur¬ 
 gical diseases. The large and constantly expanding Johns Hopkins Hospital, 
 a model of its kind, with accommodations for both pay and free patients, and 
 well-organized general and special dispensary services, was opened in 1889. 
 
 CHARITIES. 
 
 Baltimoreans have always been notable for charity, and here, as elsewhere, 
 organized charity began with personal relationships, religious organizations, 
 and race groups, and developed later into special and general relief systems. 
 The public treasury was successfully appealed to first for special needs and later 
 
22 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 for systematic help. It is beyond the scope of this work to give more than the 
 barest outline of charities and charitable institutions as they have had a direct 
 bearing upon public health and mortality. 
 
 While in the long run it may be true that in old settled countries, where the 
 laws of the relation of population, including health and mortality, are so 
 closely bound up with subsistence derivable from home lands or purchasable 
 abroad with money gained in trade, manufacture, and other services, the pres¬ 
 ervation of the lives of the very poor by private and public charity is useless 
 and even immoral; still, in a new country and particularly in a town and city 
 so situated as Baltimore, where, in general, the restrictions on population 
 growth by propagation have been relatively slight, it is probably correct to as¬ 
 sume that, on the whole, benevolence administered to the needy and unfor¬ 
 tunate, either in large groups under special conditions or to smaller groups 
 and to individuals routinely, by tiding them over difficulties in times of special 
 stress, has so far tended to increase of population and to lighten or at least to 
 deflect the force of mortalitv. 
 
 t/ 
 
 The English system of tax levies by law officers for the support of the poor 
 was applied in early Baltimore, as well as in the rest of the colony. In 1773, to 
 do away with the abuses of the system, a loan of £4,000 was made by the State 
 to Baltimore Town and County for the building of an almshouse, to be ad¬ 
 ministered by a corporate body, the Trustees of the Poor, and in connection 
 with it, there was a workhouse for the reception and lodging of vagrants or 
 other offenders committed. This almshouse, erected first on a large lot of 
 land near the present Richmond Market, moved in 1822 to Calverton, and in 
 1866 to Bayview, has remained a permanent feature of Baltimore municipal 
 charity, and during its existence has carried a large proportion of the poor and 
 destitute, for whom it has always maintained an infirmary, into which have also 
 been received indigent sick directly from the general population. For many 
 years, the Trustees of the Poor supported a few pensioners without the alms¬ 
 house. 
 
 Since early days there have existed a large number of homes for old people 
 and orphan asylums for children of each sex, often with associated schools. 
 They are usually identified with some religious sect or racial organization, and 
 several have accumulated handsome endowments. 
 
 About 1800, societies, based on racial ties, were first organized to help, advise, 
 and protect individuals of certain races and their descendants. The most im¬ 
 portant were the German (1784), the Hibernian and the St. George (1803), St. 
 Andrews (1806), and the Hebrew Benevolent Society (1834). Out of all these, 
 various benevolent activities have grown. 
 
 The great increase of immigrants during the fourth and fifth decades of the 
 nineteenth century included many who were destitute, and by 1849, poverty 
 and even pauperism having become a very serious question, the Association for 
 the Improvement of the Poor was organized on a broad and representative 
 basis. This was succeeded by the Charity Organization Society in 1881 and the 
 Federated Charities in 1908. In the meantime, during the Civil War, the calls 
 upon privately supported charities had become so overwhelming that a num¬ 
 ber of these agencies found it necessary to obtain aid from the city government. 
 In 1870, 7 institutions received $22,000 city aid, and by 1896, 51 were dividing 
 $277,275. 
 
PHYSICAL AND SOCIOLOGICAL DATA CONCERNING BALTIMORE 
 
 23 
 
 The St. Vincent de Paul Society, growing out of parisli conferences in 1865, 
 incorporated in 1869, and since widely extended, is the representative Catholic 
 society for general relief. It is closely affiliated with the large number of or¬ 
 phanages, homes, schools, and other benevolent institutions maintained by 
 members of the Catholic church. Two of these, in which large numbers of 
 children have been received, are the St. Vincent’s Orphan Asylum and St. 
 Elizabeth’s Home for Colored Children, the latter established in 1879. 
 
 The most conspicuous endowments for public aid have been the Henry Wat¬ 
 son Children’s Aid Society, $100,000 (1880), and the Thomas Wilson Sana 
 torium for Sick Children, $500,000 (1880). In close connection with the latter, 
 operates the Babies’ Milk Fund (1904), with its large number of welfare sta¬ 
 tions and nurses for babies. These two institutions have doubtless exercised a 
 large influence in late years in decreasing the mortality among the young. 
 
 During the last 20 years, charity and benevolent societies have multiplied, 
 expanded, and coordinated, and have covered the field of nursing, tuberculosis, 
 playgrounds, athletics, and the like. Many local and city-wide associations for 
 general betterment of living conditions have been formed. Among the most ac¬ 
 tive of the latter is the Woman’s Civic League, which has exerted an important 
 influence on measures to promote the public health, especially in connection 
 with improving the milk-supply. The union of 14 of the more important benevo¬ 
 lent organizations in the Alliance of Charitable Agencies in 1914 has re¬ 
 sulted in expansion and better coordination of city-wide benevolence. The 
 Hebrew Benevolent Association, upon which unusual demands had been made 
 on account of the large influx of oppressed Jews, particularly from Bussian 
 Poland, during the past 30 years, had already consolidated and expanded their 
 work in a manner somewhat similar. 
 
 Fraternal societies of various types have always been numerous and strong 
 in Baltimore. 
 
 Speaking broadly, the private and semi-public benevolent associations and 
 their correlated institutions have become grouped about three great religious 
 divisions, Protestant, Catholic, and Jewish, among which, however, the rivalry 
 is friendly and to a remarkable degree cooperative and free from prejudice. The 
 problems of the Catholics have been especially complicated, because of the dif¬ 
 ferences of race-stock and language, which tend to cause and to perpetuate social 
 isolation of large groups, such as, Poles, Italians, Bohemians, Lithuanians, and 
 some others, who are still largely in the first and second generations, and among 
 whom benevolent associations must naturally incline toward race-stock group¬ 
 ings. These problems obtain to but a small degree among Protestants. 
 
 The great nationality or race-stock benevolent societies, such as the Hiber¬ 
 nian, the German, the St. Andrew, and St. George Societies, agents of such 
 great importance in earlier days when organized to relieve the imperative neces¬ 
 sities of recent immigrants, have, with the decrease in the latter and the general 
 improvement in conditions, naturally diminished in importance as relief 
 organizations. 
 
 There are no conspicuously large benevolent associations conducted and sup¬ 
 ported by negroes alone, though they have their share of fraternal orders and 
 benevolent activities, especially in connection with their churches. 
 
 Accident, sick, and burial insurance in both local and foreign companies is 
 very prevalent among the whole population of Baltimore. 
 
24 
 
 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 In review it may be said that, at different times, especially during and after 
 wars and very large immigrations, there has been acute suffering from poverty 
 which has been met in part by general philanthropy, by special organizations, 
 and by contributions from the public treasury in a degree sufficient in the 
 main to prevent starvation and any large actual loss by death; that benevolent 
 associations, special and general, have protected the unfortunate, usually with¬ 
 out nursing and increasing pauperism; and that during its whole history pro¬ 
 vision for the relief of want has been made from the public treasury, and the 
 tendency during the last 50 years has been to call on the latter in increasing 
 proportions and to consolidate and to coordinate the various private and semi¬ 
 public benevolent agencies. 
 
 SCHOOLS. 
 
 The public school system was established in 1826, but before and since this 
 date there have been a number of private schools. On account of the large pro¬ 
 portion of Eoman Catholics in the population, the parochial schools, attended 
 by a considerable moiety of children of Catholic families, are of more than 
 usual importance. So far as the buildings for this purpose are concerned, there 
 is no reason to suppose that those of the parochial schools differ much from 
 those supported by the public treasury. The public schools are divided into 
 kindergarten, grammar, high, and technical schools. They are conducted under 
 a board of school commissioners. There are separate schools for whites and 
 negroes. 
 
 In 1850, according to Wynne (12), there were 25 schools, 11 male and 14 fe¬ 
 male, with 2 female and 1 male high schools. In 1848, the number of pupils 
 (all white) was 6,693, or about 260 pupils to a school. Wynne described the 
 schools of this day as filthy dirty, crowded, and ill-ventilated. At that date the 
 Brothers of the Christian Schools, the Brotherhood of St. Patrick, and Mc- 
 Kim’s Free School (endowed) accommodated some 2,000 additional pupils. 
 During the days of the clipper ship, the school authorities conducted a nautical 
 school, with a ship, for the training of boys for the sea. 
 
 During the next 60 years there was some improvement in the physical condi¬ 
 tions of the school-buildings. In his report for 1908 to the Commissioner of 
 Health, Dr. H. Warren Buckler, as medical inspector in charge of a group of 
 20 schools, which he regarded as typical, classed them as follows in regard to 
 design, structure, cleanliness, and ventilation: First class in every respect, 2; 
 average, justifying neither criticism nor praise, 10; modem well-designed build¬ 
 ings, but unclean and offensive on account of the personal habits and lack of 
 cleanliness of the pupils, 4; totally unfit for educational purposes, 4. In schools 
 of the latter class the school-rooms were too dark for the pupils to see the black¬ 
 board, the desks were misfits (all of the same size and non-adjustable), the 
 buildings were dirty and without proper toilets. The overcrowding was con¬ 
 spicuous; in a room picked at random, with a floor space of 18.5 by 12.5 feet 
 and 2 windows, there were 40 pupils. One of these schools, used for negroes, 
 beggared description. The new schools Buckler described as models for their 
 purpose. Thus, according to his report, it would seem that of the public-school 
 buildings 20 per cent were entirely unfit, 50 per cent were passable, and 30 
 per cent were to be condemned. It is probable that these were typical samples 
 
PHYSICAL AND SOCIOLOGICAL DATA CONCERNING BALTIMORE 25 
 
 of the whole number of public schools of the city. Few are situated on or near 
 small parks. A few of the schools have large yards, but for the most part the 
 playground space is seriously restricted. Largely through the initiation of 
 Dr. Buckler, within the last few years “ open-air ” schools for delicate children 
 have been established in connection with several schools. 
 
 From the reports of the different medical inspectors, the same conditions as 
 to structure and overcrowding obtain in the parochial schools. 
 
 There are a large number of private schools, both elementary and preparatory 
 for college, for both boys and girls. The general hygienic conditions of these 
 are good, and some are models. They are attended by a larger proportion of 
 children than is usual in an American city. 
 
 DWELLINGS. 
 
 The earlier dwellings of Baltimore Town were of wood; the first brick house 
 was built in 1740. It was not until after the rapid growth of the town after 
 1780, in an area surrounded by natural obstructions to expansion and under 
 conditions demanding warehouses and residences near the water-front, that 
 the construction of brick dwellings in closely built blocks became the custom. 
 Wood was abandoned as a building material because of danger from fire, and 
 brick was adopted on account of the great abundance of excellent clay near at 
 hand. Stone, plentiful in nearby quarries, was often used in foundations and for 
 public buildings, but was never a serious competitor of brick in dwellings and 
 warehouses. * jj W] 
 
 The early streets being comparatively wide, the rectangular squares into 
 which the town was laid off afforded ample space for the erection of houses of 
 two or three stories in height in compact blocks with sufficient provision for light 
 and air, front and back. The squares are usually cut by one or several, usually 
 two, alleys varying from 3 to 10 or even more feet in width, which give con¬ 
 venient access to the rears of the houses fronting the streets on the four sides 
 of the squares. The end houses of a block, with the street or alley alongside, 
 may have light on three sides. Since the squares measure about 300 feet on each 
 of their four sides, and the houses commonly abut the paving line, there is 
 ample room for a comparatively deep yard behind each house. The lots carry 
 ownership to the center of the alley alongside or in the rear, the alleys being pri¬ 
 vate property dedicated to the convenient use of the occupants of abutting 
 houses. The streets vary from 30 to 80 or more feet in width from house to 
 house. Since the stage and wagon roads from north, south, east, and west, led to 
 the water-front and were necessarily broad to accommodate the heavy traffic 
 wagons plying in and out of town, with the growth of the town along them, 
 they served as wide avenues radiatiug from the lower city like the ribs of a 
 fan, sufficiently distant from each other, however, not to interfere seriously 
 with the regular arrangement of streets running north and south and east and 
 west. 
 
 The dwellings of the typical city square of the better sort abut the foot-pave¬ 
 ment and are placed often in unbroken rows, for the whole length of opposite 
 sides of a street. In this case the block is bisected by a single 10 to 20 foot 
 alley, directly in the rear of each row of houses. The four houses at the corners 
 
26 
 
 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 of the square have light and air on three sides and all the rest on two sides. The 
 whole center of the square is open, except for the board fences which separate the 
 yards in the rear of each house. In other cases, blocks of houses, some with 
 less deep yards, will face three or even four sides of a square, which in this case 
 will be traversed completely or incompletely by a second or even a third alley at 
 right angles to the first. In this case, several more houses, placed necessarily 
 alongside of alleys, will have three free sides. Each yard opens upon its border¬ 
 ing alley by a gate. Only occasionally in the closely built up sections of the 
 city are any of the houses completely detached, but not infrequently in the 
 richer districts there will be one or more side-yards where owners have double 
 lots, or front yards when the houses are set back from the street. Since a lot may 
 be at least 150 feet deep, even large, deep houses may be separated by at least 
 100 feet from rear to rear in a block with a single bisecting alley. In houses so 
 situated, the amount of light and air available for each house depends entirely 
 upon its design and the width of the lot. 
 
 From these optimum conditions, there is every variation to closely built 
 squares with nearly every available foot occupied by buildings, the mass of 
 which are used for human habitation. In the first place, in the best squares 
 there are often stables and coach-houses, or in recent times garages, at the 
 rear of some of the lots. The latter, in older parts of the city, often were also 
 the seat of large or small houses or “ quarters ” for domestic servants—negro 
 slaves in former generations. In the poor districts of the city, especially in the 
 south and southeastern sections near Jones Falls and the harbor and the basin, 
 but abundantly found as foci in nearly all parts, there are numerous squares 
 almost solidly built. In general, this has occurred in one or both of two ways: 
 (1) By building a single or double row of houses along the intersecting alley or 
 alleys or houses about closed courts within the square; (2) by additions on 
 the rear of the original houses. Many such built-up alleys, 8 or 10 feet wide, 
 extending through a number of squares and later accepted by the city, have been 
 dignified by the name of streets. These alley and court dwellings have existed in 
 the oldest sections of the city from at least the latter part of the eighteenth 
 century, and these types of intra block building have so extended that in the 
 lower southern, southwestern, and in much of the western districts they are 
 characteristic features. It is not unlikely that they are inhabited by as much 
 as one-eighth of the total population. The crowding of squares by the addi¬ 
 tions to the rear of dwellings facing streets is of more recent origin, but in 
 many parts of the city, particularly in the southeastern segment, extending 
 on both sides of Jones Falls down to and including Fell’s Point, this condition 
 has existed for many years. As a result of this type of building activity in 
 many squares, at least four-fifths of the surface is covered with rambling and 
 interlocking buildings, attached to the rear of old residences; all, except when 
 the front lower rooms of the latter are transformed into shops, are used as 
 dwellings. 
 
 In the older sections of the city near the water, especially at Fell’s Point, 
 there remain dwellings typical of the early city. These range from single¬ 
 room houses and two-room 1 or 2 story houses to mansions of 10 or more rooms. 
 The single room, two, three, and four-room houses were built on broad as well 
 as on narrow streets and on alleys and courts. The early small houses had com- 
 
PHYSICAL AND SOCIOLOGICAL DATA CONCERNING BALTIMORE 27 
 
 paratively small windows, but they were well built, and as houses or dwellings, 
 apart from lack of light and air when closely grouped in alleys and courts, 
 were fit. It was the six or nine room house, with three rooms to the floor, that 
 was so often especially ill-suited in design for health. In many of these houses 
 the entry is direct into the front room, which opens into a center or hall room 
 without windows. The back room is either dining-room, with a single window 
 and a narrow kitchen behind, or combination dining-room and kitchen. From 
 the center room run the stairs, and on the two upper floors there is often a 
 central room without windows, but in some houses of this class there is ventila¬ 
 tion of these rooms by windows on shafts or by skylights. It is possible that 
 these dark rooms were not used for sleeping-rooms, but as hallways and as 
 closets, by the first occupants. Certain it is, however, that when these houses 
 passed into the hands of poorer people, especially recent immigrants, the dark 
 rooms came to be used as living and sleeping quarters. It was against this type 
 of house especially that the ordinance of 1886 was intended to apply. It is 
 likely that, by this time, houses of this type had long since ceased to be built. 
 The common device used in lighting the middle room of a house three or more 
 rooms deep is to have a space for a rear window in the middle room, by nar¬ 
 rowing the back of the building, the rooms in the latter in turn being lighted by 
 side, or, in the case of the last room, by end windows. The lower hall, now al¬ 
 most invariably the entrance, receives light from a window light in the front 
 door, and the upper halls from a broad transom in the roof. In this way, among 
 others, fairly w T ell lighted and ventilated houses are constructed in close blocks. 
 In many houses there is no or only one room over the back building, on floors 
 above the first. The larger houses of the richer classes, varying greatly in de¬ 
 sign, are characterized by comparatively large rooms with very high ceilings, 
 but in many one or more of the rooms on each floor are lacking in light. In 
 them, however, attic rooms, often used as bedrooms for servants, were often 
 dark or lighted only by skylights. In many of the smaller houses built after 
 the ordinances of 1886 and 1908, rooms on the second and third floors, used as 
 sleeping-rooms, are lighted only by immovable skylights and are thus defective 
 in ventilation. 
 
 The houses for the most part have cellars for storage and for heating-plants 
 under the main structure. In many parts of the city, especially upon made 
 ground and in the lower sections and elsewhere, on account of the numerous 
 springs, much difficulty has been experienced in keeping cellars dry. On this 
 account the early ordinances prescribed methods of construction intended to 
 prevent access of water to cellars, and automatic drainers have been used to 
 dispose of water entering cellars by seepage. From early times, in both small 
 and large houses, in higher parts of the city and especially on hillsides, half 
 cellars or basements with half or less than half their height below the surface 
 of the ground and lighted by windows, have been used not only for basement 
 kitchens and laundries, but for dining-rooms and, among the poorer people, as 
 sleeping-quarters. In the older, larger houses, occupied by people who can 
 afford domestics, the basement kitchen is the rule. These are usually well lighted 
 for their purpose by ample windows. 
 
 The typical block dwelling of the last 75 or 50 years is from 14 to 18 feet 
 front by 30 to 35 feet in depth, and of 2 to 4 stories. The cellar or basement, 
 
 3 
 
28 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 lighted by windows in front and behind, and in end houses on one side, has a 
 furnace-room with storage space for fuel, a kitchen at the rear, and sometimes 
 a laundry. On the first floor is the narrow entrance hall, approached from the 
 street by stone steps and lighted by a large window-light in the front door. 
 Opening on the hall is the comfortable front parlor, with its one large or two 
 smaller windows looking on the street. Behind this is the dining-room, entered 
 from the hall or parlor or from both. This room is poorly lighted by side win¬ 
 dows, if the kitchen, as is sometimes the case, is on the first floor, or by one or 
 more rear windows, if a first-floor kitchen behind the dining-room is narrower 
 than the latter. If the kitchen is in the basement, the dining-room will, in the 
 absence of a back building, be well lighted. A center room, poorly lighted from 
 the dining-room, or from a narrow area window, is not uncommon. The stairs 
 lead from the entrance hall to the second floor, with its front bedroom oc¬ 
 cupying the whole width of the house, or with a space the width of the first- 
 floor hall forming a bath and toilet room. More often the bath-room is in the 
 center of the house, off the stair landing, if there is an area light, or in the rear 
 over the kitchen. The rooms over the dining-room and kitchen, if there be 
 one, have ample windows. The third story resembles the second. The kitchen 
 wing may have on the second floor a bath-room and one or more bedrooms with 
 adequate light. 
 
 There have always been, beyond closely built up sections, larger and smaller 
 detached houses, with ample windows, and often surrounded by large grounds 
 and even parks. Many fine suburban homes have had to give place in the course 
 of time to the growing city. In the last 20 or 30 years, there have grown up 
 in the northern and western suburbs, especially, large settlements of detached 
 houses with large grounds and ample shade trees, resembling the New England 
 town or the western cities, but on the whole, the extension of the city into the 
 suburbs has been characterized by the building of rows of block houses. 
 
 HEATING. 
 
 All single dwelling structures built, until very recent years, had in nearly 
 every room a fire-place, in which was burned either wood or coal, or to which 
 a stove w r as attached. During the last half of the nineteenth century, latrobe 
 stoves (burning hard coal, one set in the parlor and one in the dining-room, 
 and fitted with flues to convey heated air to the rooms above) were very gen¬ 
 erally used. First in large and later in small houses, these gave place to the 
 cellar furnace, heating first by hot air and later by the usual steam or hot- 
 water radiators. Wood or coal fires are still much used in living or sitting 
 rooms by those who can afford them. 
 
 TENEMENTS. 
 
 The comparatively few large tenements of the traditional type are poor in 
 design and structure, and the same is to be said of those made by remodeling 
 and adding back buildings to large and often handsome old dwellings, from 
 which the owners or occupiers of former days have moved. Tenements of both 
 these classes abound in dark hallways, narrow passages, and dark, ill-ventilated 
 rooms, and the buildings often occupy nearly the whole of the lots. In some 
 
PHYSICAL AND SOCIOLOGICAL DATA CONCERNING BALTIMORE 29 
 
 districts whole blocks of houses have been remodeled into crowded tenements. 
 Tenements of this type are most common in the old part of the city in the 
 district south of Saratoga Street, along Jones Falls (both sides), and ex¬ 
 tending well into Fell’s Point; on Lexington and neighboring streets for some 
 distance west of Lexington Market; and in sections bounded by McCulloh 
 Street on the east and Orchard Street on the south, and extending north and 
 west, particularly along Druid Hill and Pennsylvania avenues. Tenements 
 and similar several family dwellings of these classes are occupied for the most 
 part by people of the recent migrations, especially Polish Jews, Hungarians, 
 Russians, and some Poles, and others, who, on account of their comparative lack 
 of means, have had on their arrival to take such quarters as were available. As 
 they prosper, they either take better quarters, or move into single-family 
 dwellings. The large tenement buildings so common in New York and in 
 many foreign cities are totally lacking in Baltimore. 
 
 Lodging-houses .—The practice, particularly among families with compara¬ 
 tively large houses, wdio for one reason or another desire to add to their income, 
 to let one or more rooms to lodgers, with or without meals, has been common in 
 all sections of the city, and there are also large numbers of typical boarding¬ 
 houses. In many such cases this practice leads to the use by the family or by 
 the lodger of crowded quarters, often in dark rooms. In recent years many im¬ 
 migrants have crowMed whole families into one or two rooms rented from fam¬ 
 ilies of their own nationalities. This custom is said to be particularly common 
 among Poles, Polish Jews, Russians, Lithuanians, and Hungarians. 
 
 A lodging house of another type is the 5 or 10 cent house, accommodating 
 men on the floor, bunks, or beds, and commonly styled “ flop-houses.” These 
 are fairly numerous near the water-front, and are patronized by seamen, oyster- 
 men, ne’er-do-w T ells, and occasionally by tramps. Their population has been 
 relatively small. 
 
 APARTMENTS. 
 
 In recent years, many large and small apartments ha.ve been constructed, 
 and numerous old houses have been transformed into apartments. All of these, 
 as in other cities, vary widely in the space, light, and ventilation they afford, 
 and many sections of the building code of 1908 w T ere aimed at the control of 
 these and of the lodging and boarding houses. 
 
 LAW ENFORCEMENT IN REGARD TO LIGHT AND AIR IN 
 DWELLINGS, AND TO PREVENT OVERCROWDING. 
 
 The laws on these matters, which date only from 1886, have at no time been 
 systematically enforced. The building inspector’s office has passed on plans 
 permitting dark rooms and improperly lighted and ventilated rooms in block 
 houses and in apartments, in direct contravention of the ordinance of 1908. 
 The activities of the Health Department from 1916 to 1919, at least, in regard 
 to boarding and lodging houses and apartments, have been confined to en¬ 
 deavors to enforce the requirements in regard to cleanliness, toilets, and the 
 like. 
 
 There are not now, and there never have been, any accurate data concerning 
 the proportional distribution of the population among good and poor dwellings. 
 
30 
 
 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 In periods of very rapid growth in population, housing conditions probably 
 always have been inadequate, with resulting overcrowding. This has been the 
 fault of the immigrants, for no reasonable person could expect the residents 
 to anticipate population movements and provide beforehand for uninvited 
 guests. The immigrant comes at his own risk of finding a home and the means 
 to support it, and he recognizes these limitations. Residents build houses to 
 meet demands of those with money to fill their wants, and doubtless often before, 
 as from 1910 to 1915, there were in Baltimore many unoccupied dwellings. 
 Certainly during that period there was no excuse for overcrowding, though this 
 existed in many parts of the city. How much of this was due to choice and how 
 much to inability to pay moderate rents it is impossible to estimate accurately. 
 
 It may be assumed with safety that, throughout its history as a city, the 
 great mass of the white population has been reasonably well housed, and that 
 since an early date most of those of Anglo-Saxon descent have lived in well- 
 built one family dwellings, much superior in room, air-space, and light, at 
 any given period, to those obtaining in most European and other American 
 cities. 
 
 Representatives of other white races have established themselves on the 
 whole on the same footing, after immigration, as they have found means. 
 The Germans, German Jews, Irish, Bohemians, and the Italians have achieved 
 this station in the order of their coming; other races are in process. 
 
 The description of Wynne (12), written in 1850, except for the last sen¬ 
 tence, applies substantially today: 
 
 “ The houses occupied by the laboring classes have usually a 16-foot front, a depth of 
 30 or more feet, are two to three stories high, and are unvariably of brick. Behind the 
 main building, there is usually a back building of the same height, and a yard with a 
 privy and a hydrant. (Both these now displaced in favor of interior toilets and water- 
 supply.) These houses are for the most part occupied by single families, but are some¬ 
 times underlet to poor persons. The system of a number of families occupying the same 
 house does not prevail to the same extent as in some other places and is confined to 
 the very poor. Whole streets, however, in the western part of the town are occupied 
 by a wretched population, crowded together in a most unseemly and unhealthy manner.” 
 
 In so far as the last sentence applies to whites, it is probable that it fitted the 
 great number of Irish and German immigrants forced to leave their native 
 lands during the previous few years and who had been here too short a time 
 to establish themselves. The same fate of necessity overtook the crowds of 
 Polish Jews who arrived in the last two decades of the nineteenth century. This 
 must always have affected those immigrants whose coming was influenced more 
 strongly by repellant than by appellant forces, but in each case they have no 
 doubt found the housing conditions much better than those they left. 
 
 It has been with the negro, however, that poor housing conditions have been 
 especially associated, and in many ways with truth. It is difficult to decide which 
 on the whole was the better (or the worst) housed in Baltimore, the free or 
 the slave negro. For a certain period the death-rate was greatest among the 
 latter. There was every incentive for the masters of slaves to house them as well 
 as practicable, and many of the free negroes, both before and after 1865, were 
 skilled artisans and earned good wages. For the latter, the chief reason for 
 alley residence was not financial but social. Indeed, there are many rows of 
 alley houses fully equal and often superior to many “ street houses,” and when 
 
PHYSICAL. AND SOCIOLOGICAL DATA CONCERNING BALTIMORE 31 
 
 the family is not too large afford healthy dwellings. Again, within the last 
 20 years, many negroes have lived in well-built, large houses, on wide streets, 
 fully the equal of those of many of their white neighbors, and in every way 
 superior to the crowded dwellings of many of the more recent white immigrants. 
 In every way the negro’s status is racial; whatever his means, he was often 
 limited to alley dwellings, because on account of opposition of the whites he 
 could not gain entrance to a street block. In most neighborhoods, when one or 
 two negro families succeed in getting a house in such a block, the whites will 
 move out, and the whole block will in a short time be inhabited by negroes. 
 Thus they have gained block after block in many streets. It is certain that the 
 negro, on the whole, during the last 10 or 20 years, has been better housed than 
 many whites of several races of recent arrival. 
 
 Ownership of the home has been a marked characteristic of Baltimoreans. 
 This has been facilitated by the ground-rent system, by which occupation of land 
 is obtained without immediate capital outlay, the cheapness of building, and 
 the large number of savings banks and building and loan associations, ready to 
 lend money on liberal terms for home-building and home-owning. Whereas in 
 some quarters of the city many houses, even blocks of houses, are owned and let 
 by large estates; in general, building has been carried on by contractors with a 
 view to immediate sale to occupiers. In consequence, a very large part, probably 
 the majority of the houses stand in the names of the occupiers. This custom ex¬ 
 tends to the so-called common laborer. As would be expected, under these con¬ 
 ditions, in normal times rents are comparatively low. 
 
 Though overcrowding undoubtedly occurs in certain sections and among 
 certain race stocks, in general it can not be said to obtain for any large section 
 of the population, for according to the United States census of 1910, there 
 were 101,905 dwellings to 118,851 families and a population of 558,485. 
 
PART II.—HISTORICAL DEVELOPMENT OF THE 
 HEALTH DEPARTMENT AND OF HEALTH 
 LAWS AND REGULATIONS IN BALTI¬ 
 MORE AND THE STATE OF 
 MARYLAND. 
 
 Chapter III. —Ideas underlying the Public Health 
 
 Laws of Baltimore. 
 
 Tlie early health laws of Baltimore were concerned entirely with prevention 
 of the entrance and spread of certain acute febrile diseases. In seeking to in¬ 
 terpret the ideas underlying these laws and their administration, it is necessary 
 to review briefly the knowledge and beliefs which obtained at that time in 
 Europe and in North America concerning the natural history, and especially 
 the modes of dissemination, of the prevalent communicable diseases of the time. 
 In Baltimore and in Maryland, as along the rest of the Atlantic seaboard, in 
 1797, the diseases of this class most usual, most dreaded, and most written about 
 were malarial and yellow fevers, diarrhoea, dysentery, and small-pox. Of the 
 malarial fevers, the intermittent and remittent, or bilious remittent, were 
 common and very fatal. At least two epidemics of yellow fever had been 
 recently experienced. Small-pox was a constant menace. 
 
 Typhus fever, measles, scarlet fever, and influenza are known to have visited 
 the town as occasional epidemics, but had not yet become endemic. Whooping- 
 cough and membranous croup were certainly endemic, but faucial diphtheria 
 was rare. Of the diarrhoeal affections, dysentery, cholera morbus, and cholera 
 infantum were prevalent and very fatal. Charles Caldwell, of Philadelphia, 
 writing in 1802, stated that the latter affection was far more common and 
 more fatal in American than in European cities and suggested that it be called 
 Americana pestilentia infantum. Pulmonary tuberculosis was common, as per¬ 
 haps also was pneumonia. Gonorrhoea and syphilis were well known. Typhoid 
 fever had not yet been differentiated as a distinct disease. Bubonic plague, in 
 typical form at least, had never reached America, and fear of this disease was 
 traditional only. Relapsing fever and the English sweating sickness had never 
 been recognized in Baltimore. There were three deadly and much feared “ pes¬ 
 tilential ” diseases, small-pox, yellow fever, and typhus fever, against the en¬ 
 trance of which quarantine and other protective measures were likely to be 
 invoked. 
 
 Many of the physicians of Baltimore ToAvn were men of talent, learning, and 
 keen powers of observation and reasoning, and a goodly proportion of them had 
 been trained in England. They were well acquainted with the great British 
 writers on medicine and some were acquainted with the writings of Hippocrates, 
 Galen, and other ancients and with the continental writers of the sixteenth, 
 seventeenth, and eighteenth centuries. In regard to the natural history of 
 
 33 
 
34 
 
 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 the diseases at present under consideration, the most important writers who 
 influenced them were Thomas Sydenham, Richard Mead, John Huxliam, John 
 Pringle, David Monro, John Lind, John Howard, and Gilbert Blane. 
 
 From Sydenham's (13) writings had come down not only his clear-cut 
 descriptions of certain acute infectious diseases, particularly small-pox, measles, 
 scarlet fever, and malaria, but his ideas, partly borrowed from Hippocrates 
 and other ancients and partly his own, in regard to the influence of season, 
 temperature, rainfall, telluric, and other natural conditions on epidemics of 
 disease. The teachings of Sydenham which particularly influenced public- 
 health ideas and practice in Baltimore were those that held first, that the kinds 
 of acute diseases prevalent in any given year were dependent upon the con¬ 
 stitutions of the atmosphere and that the different constitutions of the atmos¬ 
 phere and, consequently, the diseases governed by them, tended to run in cycles, 
 and second, that certain diseases were associated with particular periods of 
 the year. 
 
 Richard Mead's (14) A Discourse on the Plague, dated November 25, 1720, 
 and written in reply to an inquiry on the part of the British Government as 
 to the proper measures to prevent the entrance into and the spread through the 
 country of plague, had a most profound influence upon the English-speaking 
 world. The dreaded plague was at that time raging in Marseilles and, to the 
 consternation of many continental and British physicians and publicists, it 
 was held by the authorities and certain leading physicians of that city to be 
 non-contagious. It was feared that the practical effect of this heterodoxy 
 would be relaxation or even abandonment of the usual methods and activities 
 against the disease, resulting in its general spread over Europe. Mead's recom¬ 
 mendations, which were enacted into law on December 8, 1720, superseded the 
 former laws on thfs subject dating from the time of James I. As is clearly 
 shown from his discussion of the subject and from his later writings, Mead's 
 “ recommendations," as they are commonly called, were based upon an inti¬ 
 mate knowledge gained by travel in his youth of the quarantine system of the 
 Mediterranean seaports, and particularly that of Venice, where the system was 
 established in 1484. Of more importance than the maritime quarantine fea¬ 
 tures, however, were the measures recommended for the local control of the 
 plague should it gain a foothold in the country. When digested, these resolve 
 themselves into 13 principles of action, which cover, in all essential particulars, 
 present-day procedure and practice employed in attempting to control the con- 
 tactive diseases. 
 
 Pringle (15) treated particularly of the acute diseases that attacked the 
 British army and the conditions under which they arose in the campaigns in 
 Flanders and in Germany in the years 1743 to 1748, inclusive. He laid great 
 stress upon the influence of wetness and dryness and of heat and cold upon 
 the prevalence and severity of the diseases which he classed epidemic. Pleurisy, 
 pneumonia, and rheumatism were common in the spring, and malarial fevers 
 in the spring, summer, and autumn. Dysentery, often accompanied by liver 
 abscess, was prevalent, especially in fixed camps, in the hot, close summer 
 weather. He regarded this disease as contagious and ranked it as among the 
 malignant and pestilential diseases. It is evident from his descriptions of the 
 anatomical lesions that he was dealing with both the croupous (bacillary) and 
 
DEVELOPMENT OF HEALTH DEPARTMENT AND HEALTH LAWS, ETC. 35 
 
 the severely ulcerative (amoebic) varieties. He held that “ hospital fever,” which 
 was very prevalent in the crowded hospitals, was identical with jail distemper 
 (typhus), but, from his descriptions of cases, it would appear that under this 
 name were classed many cases of pyaemia and septicaemia in connection with 
 wound infection and dysentery. From the frequent occurrence of swelling of 
 the parotid glands as a complication of malignant hospital fever, it seems 
 likely that typhoid fever was also prevalent. Of particular importance in con¬ 
 nection with the development of methods designed to control diseases by ren¬ 
 dering their causes inactive through the action of chemical agents were Pringle’s 
 exact experiments on the effects of various substances, such as alkalies, gums 
 (as myrrh and camphor), Jesuit’s bark and acids, both mineral and vegetable, 
 in preventing and arresting fermentation and putrefaction. 
 
 David Monro (16), writing of the diseases met with by the British forces in 
 the campaigns in Germany in 1761 to 1763, dealt with the same affections de¬ 
 scribed by Pringle. His observations, however, on the general hygiene of 
 camps, ships, and hospitals were of great importance and must have exerted a 
 very decided influence. He laid especial stress upon bad water as a cause of 
 disease in soldiers. Next to the unwholesome vapors arising from marshes 
 and corrupt standing water, he held excreta to be the chief causes of diseases 
 in camps. He recommended that in camps every precaution should be taken 
 to remove filth and to provide proper latrines, and regarded the frequent chang¬ 
 ing of camping grounds as most important. He gave definite and specific rules 
 for the organization and management of military hospitals, particularly in re¬ 
 gard to the care and cleanliness of the patients and of the bedding and floors. 
 He condemned overcrowding and urged that provision be made for purification 
 of the air of wards by ventilation and otherwise, that those ill with contagious 
 diseases be put in separate wards, and that proper laundries be provided where 
 bedding and clothes could be thoroughly washed and aired. 
 
 John Lind (17, 18), the well-known authority on the diseases of sailors and 
 on the hygiene of ships and hospitals, and for many years physician to the 
 Haslar Naval Hospital, in a series of papers published between 1757 and 1776, 
 added greatly to the knowledge of the natural history of scurvy, jail or ship 
 fever, malarial and yellow fevers, and dysentery and the methods of their pre¬ 
 vention. In regard to ship or typhus fever, he pointed out that one ship’s crew 
 was frequently infected from another by the transfer of infected men, particu¬ 
 larly of newly impressed men from Ireland and Scotland, and by visits of sea¬ 
 men from ship to ship. He recommended that these practices be interdicted and 
 that all impressed men be held under observation for a time and be given 
 baths and clean clothes before being assigned to ships. He laid great stress 
 upon proper cleanliness and ventilation of ships and upon better hospital quar¬ 
 ters on shipboard. Lind established the fact that ship fever can spread from 
 the sick to the well over no great distance and that those living in houses near 
 infected persons are in no danger, provided communication be cut off. He 
 observed that in the open air the cause of the disease did not spread over 50 
 feet, and that the heat of an oven, such as will destroy animal life, effectually 
 destroys “this infection.” He found that the burning of brimstone over char¬ 
 coal, used as a method of disinfecting ships “ does not destroy some species of 
 vermin, particularly lice.” Lind showed that dysentery often attacked those 
 
36 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 who used privies that were used by dysentery patients, that this disease often 
 spread rapidly through a hospital ward after the admission of a dysentery 
 patient, and that the virus seemed to be spread particularly by the clothing, 
 bedding, and utensils of dysentery patients. 
 
 The intermittent and remittent malarial fevers he held to be the common 
 autumnal fevers of all hot countries, but perhaps different from yellow fever. 
 To Lind belongs the credit of bringing to general attention the value of a 
 course of Jesuit’s bark (cinchona) in preventing malarial fevers, a fact which 
 he stated had been demonstrated early in the century by Kramer, physician to 
 the Imperial army in the campaigns in Hungary (1717-1718) along the 
 marshy Danube, then one of the sickliest countries of Europe, and later by 
 the English in their “ factories ” on the Guinea Coast. Lind quoted three phy¬ 
 sicians well acquainted with yellow fever in the island of Jamaica, as holding 
 that yellow fever was not contagious, “ contrary to the opinion of the Ameri¬ 
 can colonists who constantly apprehend its importation from the West Indies 
 in ships and in goods.” Gilbert Blane’s studies of the diseases of sailors 
 and of warm climates exerted an influence only second to Lind. 
 
 The work of John Howard (19, 20), the philanthropist, emphasized the fact 
 that jails in Great Britain and Ireland were the particular homes and breeding- 
 places of fevers, especially of typhus, and indicated the importance of clean¬ 
 liness and care in their control. He also brought to the general knowledge of 
 the English-speaking peoples the elaborate quarantine provisions of the Medi¬ 
 terranean ports, with their systems of hospitals and lazarettos. To Howard’s 
 influence has been attributed some of the most stringent features of the Brit¬ 
 ish quarantine system when it was remodeled just about the time that the 
 early health laws of Baltimore were in the framing. 
 
 In regard to water-supplies and sewerage disposal, apparently the only 
 standards were taste and a not very highly developed sense of common decency. 
 It will be recalled that after the fall of Home, in the fifth century, the Euro¬ 
 pean world well-nigh if not entirely lost appreciation of the importance of pure 
 water and of the sanitary disposal of human waste. It is well established that 
 these sanitary practices, dating from at least the time of Ninevah, were car¬ 
 ried to the Greek cities by the Phoenicians and later were highly developed by 
 the Romans, who introduced them to France, Germany, and England. At the 
 opening of the nineteenth century, drinking-water was obtained from pol¬ 
 luted springs, wells, lakes, and rivers, and the efficient use of sanitary sewers, 
 on any large scale at least, had fallen into desuetude. 
 
 The development of public-health administration in Baltimore has been so 
 intimately bound up with the evolution of the conceptions conveyed by the 
 terms of contagion and infection that at this point it is necessary to trace these 
 briefly. 
 
 CONTAGION AND INFECTION. 
 
 Diseases in general and, later, epidemic diseases in particular, were first as- 
 scribed to the will of deities, the actual instruments of whose design or wrath 
 were thought to be evil spirits or specially created poisons. The latter were 
 to be avoided by segregation, by flight, and by charms, and the former were 
 to be placated by penitential sacrifice and worship. It is common knowledge 
 that, in certain countries of Europe where science has not been cultivated and 
 
DEVELOPMENT OF HEALTH DEPARTMENT AND HEALTH LAWS, ETC. 37 
 
 religious superstition and intolerance have been to but a slight degree over¬ 
 thrown, those ideas are still widely prevalent. In illustration of the tenacity 
 with which these ideas may cling, even in a country notable alike for the 
 strength of religious superstition and ecclesiastical tyranny and for great con¬ 
 tributions to science, it may be permissible to recall that, when cholera threa¬ 
 tened Scotland in 1853, the Presbytery of Edinburgh addressed the Britisli 
 Government, suggesting the appointment of a period of fasting and repen¬ 
 tance with the object of appeasing Divine Providence and so turning away a 
 pestilence with which a sinful people was threatened. 
 
 The idea of the invasion of the body by harmful agents from the outside is 
 of very remote origin. In very ancient times, the peoples of the Mediterranean 
 basin, from whom western civilization derives its origin, recognized that of the 
 great mass of diseases there were some, especially those affections that spread 
 as plagues and pestilences and those that were particularly identified with 
 certain places, which had in common a constant symptom—fever. It was thus, 
 no doubt, that all diseases fell naturally into one of two groups, the febrile 
 and the non-febrile. With expanding knowledge, these groups, and the febrile 
 group more especially, were submitted to critical study that led to the recogni¬ 
 tion of classes distinguished by other qualities. Until very recent years, with 
 few exceptions, the great mass of the diseases which man has sought to avoid and 
 to control belonged to the group of which fever is a prominent symptom. Hence 
 it occurred that, from their beginning, health departments were concerned 
 chiefly with acute febrile diseases, and especially with those that came from 
 without, such as plagues and pestilences, and the spread of which experience 
 showed was directly associated with communications. The febrile diseases 
 indigenous to places and so long regarded as necessary evils received less at¬ 
 tention and were apt to be treated with a contempt bred of familiarity or 
 accepted with a feeling of helplessness. 
 
 At the period of the framing of the first health laws of Baltimore, a sharp 
 distinction was very generally recognized between those acute febrile diseases 
 either observed to be or believed to be conveyed by direct or indirect contact 
 from the sick to the well and those for which this method of transmission 
 was not in evidence or was at least denied. These conceptions had been grad¬ 
 ually developed over a long period of history. The causative agents of the 
 contactive or contagious ( con-tango, touch) diseases were thought to be emana¬ 
 tions carried in some instances by the breath and in others by the secretions 
 or the excretions of the bodies of the sick. These disease-producing ma¬ 
 terials might be the products of secretions or of poisonous substances de¬ 
 rived from the breaking-down (putrefaction) of some elements within the 
 bodies of the sick. These substances were generally held to be specific for each 
 contagious disease; that is, the disease-producing cause emanating from an 
 individual with a particular contagious disease was capable of producing that 
 disease only (the emanations of a small-pox patient could produce small-pox 
 only and not measles or scarlet fever or some other disease). The causative 
 agents for the second class of febrile diseases were thought to have their 
 origin in the decay, fermentation, or putrefaction of dead organic matter, some¬ 
 times vegetable, sometimes animal. It was held that in fevers proceeding from 
 putrefaction of organic matter outside of the body, none of the secretions or 
 
38 
 
 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 excretions of the sick were capable of producing the same disease in others. 
 The atmosphere was held to be the sole carrier of harmful agents of this class, 
 and, as it was vitiated or infected (inficio- taint, corrupt, or spoil) with or by 
 them, the term infectious diseases was applied to febrile diseases whose causes 
 were believed to be so conveyed. 
 
 From time immemorial it had been popularly accepted that the malarial 
 (mala aria —bad air) fevers were caused by effluvia arising from the decaying 
 vegetable material of marshes and other stagnant water or of the soil, com¬ 
 monly called marsh effluvia or miasmata (Greek, /u'as/xa—defilement). The 
 distinction between miasmatic and other epidemics was especially emphasized 
 by Lancisi (21) in his De Noxiis Palidum Effluviis in 1717. This doctrine was 
 widely accepted and fixed at the beginning of the nineteenth century, and, as is 
 well known, remained in force until recent years. 
 
 This sharply cut distinction between the terms contagious and infectious was 
 not universal, for Lind appears to use these terms as having the same meaning, 
 and Robert Hooper (22), writing in 1803 concerning certain diseases epidemic 
 in London during that year, asserted it as his opinion, “ that they are not in¬ 
 fectious; that is, they are not communicated from one person to another.” 
 At the same time, he attributed these diseases principally to causes existing in 
 the atmosphere, “ which having induced certain diseases in the human body, 
 are thereby destroyed, without producing any state of the body capable of en¬ 
 gendering particles which again can create disease; so that their action is lost, 
 after having produced their first effects.” It will be noted that his conception 
 of causation here agrees with that prevalent at the time for infectious diseases, 
 but that he uses the word infectious to convey the idea with which contagious 
 was commonly identified. According to common usage, Hooper would have 
 stated that the diseases under discussion were infectious and not contagious. 
 Indeed, Hooper, and Lind, too, in a measure, seem to have anticipated for the 
 word infectious a meaning which much later was very generally attributed to it, 
 namely, the capacity on the part of a disease to pass from one person to 
 another by any means whatever. 
 
 Nathaniel Potter (23), in his address before the Medical and Chirurgical 
 Faculty of Maryland in 1817, very clearly brought out these differences be¬ 
 tween contagious and infectious diseases. He pointed out that the ancient 
 physicians, when they spoke of contagion in connection with fevers, recognized 
 no distinction between persons and places, that the ancients in general used 
 the ephithet contagion in connection with almost every fever which could be 
 contracted by being in the place where it prevailed, and that this term was 
 never applied in a personal sense to any general diseases except plague and 
 the eruptive fevers until it was suggested for other fevers by Hieronimus Fra- 
 castorius in 1547. 1 
 
 1 In this connection it is interesting that both Potter and Maclean attributed to Fracas- 
 torius the hypothesis of febrile contagion and the fears which it engendered—all those 
 commercial impositions under the several forms of quarantine, pest-houses, lazarettos, and 
 even banishment—which were in their opinion a disgrace to civilized man. In essence, the 
 tale runs that in connection with the conflicting interests at the Council of Trent in 1547, 
 when, because of the dissensions among the members, Fracastorius, in order to advance the 
 interests of his patron and friend, the Pope, declared that a fever which had appeared at 
 Trent was eminently contagious and had a particular attraction for those of noble blood. 
 It was claimed that these assertions of Fracastorius in regard to these two particular 
 attributes of this fever overwhelmed with fear the Spanish bishops and the Emperor’s 
 
DEVELOPMENT OF HEALTH DEPARTMENT AND HEALTH LAWS, ETC. 39 
 
 Fracastorius (24) indeed held that all contagions were divided primarily 
 into three classes: (1) Those carried by contact alone, (2) those carried by con¬ 
 tact and by fomes (as examples are cited scabies, phthisis, alopesia, and leprosy), 
 and (3) those which, like phthisis and small-pox, are spread not only by con¬ 
 tact and by fomes, but at a distance. 
 
 Gradually, the febrile diseases were assigned to one or the other of these 
 two classes, and at the end of the eighteenth century the following diseases 
 were regarded as contagious: venereal diseases, leprosy, the plague or the 
 classical pest, elephantiasis, ophthalmia, small-pox, scarlet fever, measles, 
 whooping-cough, hydrophobia, and mumps. Typhus fever, the dysenteries, ma¬ 
 lignant sore throat, and pulmonary tuberculosis were included in this class by 
 some and excluded by others. To the diseases of the second class, or the in¬ 
 fectious diseases, were assigned first and foremost the malarial fevers attrib¬ 
 uted to the miasmata arising particularly from decayed vegetable matter, 
 and, according to many, dysenteries and typhus fever. It is of interest that 
 Potter (23), in 1817, excluded ophthalmia, plague, malignant or ulcerated sore 
 throat (diphtheria), and typhus fever from the contagious diseases. Anthrax 
 and glanders were apparently regarded as of little importance in man, and 
 cholera asiatica had not invaded western Europe. When it did, it was regarded 
 as non-contagious by the health officials of Baltimore. 
 
 It is to be observed that the causes of disease included in the first class were 
 derived from persons, and therefore capable of being spread only through them 
 and their immediate or intimate contactive environment, such as the air im¬ 
 mediately about them, their clothes, bedding, utensils, and the like. As a re¬ 
 sult of the efforts to control the spread of such diseases, great importance came 
 to be attached to the care of articles in intimate association with the sick and 
 to the purification by dilution or by chemical agents of the air immediately sur¬ 
 rounding those sick with or dead of these affections. It would appear that the 
 term fomes or fomites (fuel or tinder) first applied to the harmful agents 
 themselves and only gradually came to signify materials possessing qualities 
 favorable to receiving and holding the causative agents of diseases of this 
 class. Attempts at control of the spread of diseases of this class were therefore 
 logically directed to the management of persons and their immediate envi¬ 
 ronment. The causes of diseases of the second class, originating, as it was 
 believed, outside of living animal bodies from the breaking down of organic 
 material, with the consequent escape of the poisonous agents into the atmos¬ 
 phere, by which their transmission to the living body was accomplished, were 
 to be combated by interfering with development of their causes and by flight, 
 or by purification of the air, either by ventilation or by chemical agents. Pre¬ 
 vention of these diseases was, therefore, to be accomplished mainly by the control 
 of environments favorable to the origin of their causative agents. This could be 
 effected best by measures of general sanitation. They were to be avoided by 
 position, cleaning, draining, and filling. In seeking to prevent a given febrile 
 disease, the first point was to place it in its proper category. Hence, the volum- 
 
 delegates and thus contributed to the success of the Pope’s party in their efforts to remove 
 the council to the Pope’s own city of Bologna. The special point of interest is that to these 
 assertions of Fracastorius, made entirely for political reasons and it is claimed without 
 basis in actual fact, were attributed such far-reaching consequences and practices in 
 hygiene. 
 
40 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 inous discussions of the older authors as to whether a given disease was con¬ 
 tagious or infectious were not simply academic, but involved decisions of a 
 very practical nature. 
 
 It had become very widely accepted that the poisons of the contagious diseases 
 were formed in and by the blood-vessels, and that their chief portal of entry 
 to the body was through the skin, where they were absorbed by the nerves. The 
 poisons of the infectious diseases were supposed to enter through the lungs. 
 Various explanations were offered for the observed fact that the poisons of 
 some of the latter class of febrile diseases were most active at night. The fact 
 that they were par excellence air-borne satisfactorily explained the influence 
 of winds upon their spread. 
 
 While in Baltimore at least, during this period, the miasmatic or infectious 
 diseases were generally believed to be due to the direct action upon the system 
 of poisonous substances of a chemical nature, arising from putrefaction of 
 dead organic matter, there were those who held that the deleterious action of 
 an atmosphere impregnated with harmful substances of this origin was indirect; 
 that is, that, on account of the presence of these substances in the air, the body 
 was unable to obtain from it materials necessary for life with health. To 
 quote Beese (25) : 
 
 “ When by being exposed to a noxious atmosphere, or the effluvia arising from putre¬ 
 faction, whereby the pabulum of life, the air, is rendered impure, or so mingled with 
 gases, that the system does not receive the necessary nutriment from its inhalation, 
 disease is produced; we say the disease is excited by infection. These diseases may be 
 contracted any number of times by the same individual.” 
 
 According to this doctrine, infected or spoiled air was incapable of furnish¬ 
 ing the physiological requirements of the body which the latter is accustomed 
 to receive during respiration; in a peculiar sense, therefore, the air was 
 “ spoiled ” for its proper usage by the body, and the maladies resulting were 
 deficiency diseases. This conception of an indirect mode of action of the mias¬ 
 matic poisons in causing the infectious diseases conformed, as well as did the 
 idea of their direct poisoning action, with the theory of the efficacy in disease 
 prevention of the purifying of an “ infected ” atmosphere by dilution (ventila¬ 
 tion) or by chemicals. It also explained equally well the observed fact that 
 patients ill with such diseases often improved rapidly or quickly recovered when 
 removed to a “ purer 99 atmosphere. 
 
 An important distinction between the contagious and the infectious (mias¬ 
 matic) diseases was based upon the observation that one attack of one of the 
 former commonly conferred a permanent immunity against that particular 
 member of the group, whereas an attack of a member of the latter group did 
 not. However, it was acknowledged very generally that prolonged residence 
 in localities where they were prevalent was commonly associated with a toler¬ 
 ance to the causal agents of the infectious or miasmatic diseases. A sharp dis¬ 
 tinction was recognized between this tolerance and the actual immunity 
 attained against one of the typically contagious diseases. 
 
 It was not until long after this time that it became established that for a 
 goodly proportion of the diseases included among the contaetive diseases, the 
 victim of one attack does not acquire a lasting immunity, as, for instance, in 
 the venereal diseases. The doctrine held best, of course, for certain acute exan- 
 
DEVELOPMENT OF HEALTH DEPARTMENT AND HEALTH LAWS, ETC. 41 
 
 thematous or eruptive diseases, such as small-pox, varicella, scarlet fever, and 
 measles. 
 
 A very good idea of the degree to which distinctions between contagion and 
 infection had been reached in the United States by 1818 was given in the 
 publication of the learned Dr. Shecut (26), of Charleston, South Carolina. 
 Shecut held that there were two kinds of contagion; first, that which is pro¬ 
 duced by the healthy action of the vessels, as of the rattlesnake, viper, and 
 spider; and secondly, that which is produced or formed by the secreting 
 arteries under pathological conditions, as in lues, variola, and vaccinia. The 
 contagions, he held, were only generated in living animal bodies and were set 
 free in sweat, saliva, blood, pus, or breath of the diseased. When these con¬ 
 tagious products of the diseased body were absorbed in bedding or articles of 
 apparel, they became fomites which were just as capable of reproducing the 
 same specific disease as the secretory or excretory product from which the fomes 
 originated. A fomes, then, was a contagion carried not directly from person 
 to person, but indirectly from the sick to the well through the medium of an 
 absorbent material. 
 
 Infections were all generated by the decomposition of putrid vegetable or 
 animal substances or both combined, and, hence, they were the result of the 
 processes of putrefaction of dead bodies only. The contagions were communi¬ 
 cable only by contact or touch, with the absorption of the virus. 
 
 The refinement to which the distinction between contagions and infections 
 and the classification of these two definite types of disease had been carried 
 at this time are well shown in ShecuUs syllabus on page 42 of the distinguishing 
 characteristics of contagions and infections and of the elaborate classification 
 of these diseases into classes, orders, genera, and species. 
 
 The theory of the chemical nature of the causal agents of the contagious 
 and infectious diseases continued to be generally accepted until well after 
 the beginning of the last quarter of the nineteenth century. It received the 
 support of the great chemist, Liebig, who, likening these disease processes in 
 the animal body to the fermentations, argued that they were caused by fer¬ 
 ments. It was on this account that the term zymotic came to be applied to these 
 diseases. 
 
 It should not be forgotten, however, that the idea of a contagious principle 
 of a living nature, the contagium vivum or contagium animatum, is a very old 
 one. The idea that certain diseases may be caused by minute living organisms 
 was entertained by Fracastorius (24). In the last quarter of the seventeenth 
 century, it received support from the discovery of micro-organisms by 
 Kircher (27) (1671) and by Leeuwenhoek (27) (1675). Kircher ascribed to 
 minute form-like forms a casual role in bubonic plague. Lange and Haupt¬ 
 mann (27) soon after found similar bodies in the foul lochial discharges of 
 women with epidemic puerperal sepsis, and they held that other diseases, such 
 as measles, small-pox, typhus, and pleurisy, were caused by living contagions. 
 Microscopic parasites were held to be the cause of syphilis by Andry (27) 
 (1701) and of malaria by Lancisi (21) (1717). Plenciz (27) (1762) strongly 
 supported the theory that the epidemic diseases in general were caused by 
 micro-organisms. Later, fungi and kindred organisms were found in the intes¬ 
 tines of individuals with cholera and typhoid fever, in the lesions of puerperal 
 
SYLLxlBUS. 
 
 Distinguishing characters of contagions and of infections. 
 
 Contagions are to be distinguished from in¬ 
 fections. 
 
 1. In being the product of living ani¬ 
 
 mal bodies. 
 
 2. By being a secreted fluid, or other 
 
 matter, capable of reproducing the 
 same specific disease. 
 
 3. In being communicable only by con¬ 
 
 tact, or by the close approach of 
 persons, and by the absorption of 
 the matter, or fomites of con¬ 
 tagion. 
 
 4. And that under all circumstances of 
 
 the weather, whether a pure or 
 impure atmosphere, wet or dry, 
 hot or cold, etc. 
 
 Infections are to be distinguished from 
 contagions. 
 
 1. In being the product of dead organ¬ 
 
 ized bodies animal or vegetable, 
 or of both combined. 
 
 2. By being aerial fluids or gases 
 
 evolved or disengaged from the 
 foregoing, during their decompo¬ 
 sition. 
 
 3. And are in general only communi¬ 
 
 cable through the medium of an 
 impure atmosphere; i. e., the at¬ 
 mosphere which supports them. 
 
 4. Or, they are the product of an in¬ 
 
 flammatory constitution of the at¬ 
 mosphere, and hence universal. 
 
 Genera, or classification of contagions and infections. 
 
 Contagions. 
 
 Class I. Fixed or indolent contagions. 
 
 Order I. Tubercula: 
 
 Genus Elephantiasis. 
 
 Species 1. Framboesia. 
 
 Species 2. Coco-bay. 
 
 Order II. Squamae: 
 
 Genus 1. Lepra. 
 
 Genus 2. Psora, etc. 
 
 Order III. Vitia: 
 
 Genus Syphilis: 
 
 Species 1. Chancre. 
 
 Species 2. Sibbens? 
 
 Species 3. Laanda? 
 
 Order IV. Spasmi: 
 
 Genus Hydrophobia. 
 
 Species a. Rabies. 
 
 Order V. Phlegmasiae: 
 
 Genus 1. Urethritis. 
 
 Genus 2. Cynanche. 
 
 Species Cynanche maligna. 
 
 Genus 3. Pertussis. 
 
 Genus 4. Phthisis. 
 
 Species Pulmonalis. 
 
 Order VI. Vesiculae: 
 
 Genus Vaccinia. 
 
 Class II. Volatile active contagions. 
 
 Order 1. Pustulae: 
 
 Genus Variola. 
 
 Order II. Vesiculae: 
 
 Genus Varicella. 
 
 Order III. Exanthemata: 
 
 Genus 1. Pestis. 
 
 Species Orientalis. 
 
 Genus 2. Rubeola. 
 
 Infections. 
 
 Class I. Simple atmospherical infection , or 
 that which is the effect of an atmosphere 
 charged with simple septic miasma ( vege¬ 
 table effluvia). 
 
 Order I. Intermittentes: 
 
 Genus 1. Quotidiana. 
 
 Genus 2. Tertiana. 
 
 Genus 3. Quartana. 
 
 Order II. Remittentes: 
 
 Genus Remittens. 
 
 Variety Remittens biliosa. 
 
 Order III. Continuae: 
 
 Genus 1. Synocha. 
 
 Variety a. Synochula. 
 
 Variety b. Synochoides. 
 
 Genus 2. Typhus vel. Synochus. 
 
 Species Typhus mitior. 
 
 Class II. Compound infection, or that 
 ivhich is the effect of the septic miasma, 
 combined rvith azotic. 
 
 Continuation of Order III, Class I: 
 
 Genus Typhus. 
 
 Species Typhus endemica, vel Iete- 
 rodes, vel Pestis, Occidentalis. 
 
 Class III. Original and primary infection, 
 or that which is produced by azotic mi¬ 
 asma (animal effluvia). 
 
 Continuation of Order III, Class I: 
 
 Genus 1. Typhus. 
 
 Species Gravior vel maligna. 
 
 Variety a. Gaol. 
 
 Variety b. Ship. 
 
 Variety c. Camp or lake fever. 
 Genus 2. Dysenteria. 
 
 Class IV. General or universal infection, 
 or that produced by inflammatory consti¬ 
 tution of the atmosphere without regard 
 to either of the miasmata. 
 
 Order Phlegmasia: 
 
 Genus 1. Catarrhus. 
 
 Species Catarrhus epidemica. 
 
 Genus 2. Typhoid pneumonia. 
 
 42 
 
DEVELOPMENT OF HEALTH DEPARTMENT AND HEALTH LAWS, ETC. 43 
 
 peritonitis, in favus and aphthous ulcers, and in the disease of the silkworm 
 known as muskadine (Bossi, 1837, and Boehm, 1838). Henle (28, 29) (1840 
 and 1853) and John K. Mitchell (30) (1849) ably supported the doctrine of 
 the micro-parasitic origin of the acute febrile diseases. Mitchell attributed the 
 “ malarious and epidemic fevers ” to fungi, rather than to animal parasites, 
 largely because of the wider known distribution of the former. He held that 
 the purely chemical theory, and particularly the ferment theory of Liebig, were 
 totally inadequate to explain the established facts of the natural history of 
 these diseases, especially the immunity that follows recovery from the typically 
 contact diseases. 
 
 The startling facts brought out between 1850 and 1880 in the controversy 
 over the causation of fermentation and putrefaction added strength to the germ 
 theory of diseases of this class. In the meantime, the finding by pathological 
 anatomists of bacteria in the blood and in the local lesions in anthrax (Pollen - 
 der, 1855; Devaine, 1863), and in wound infections (Rindfleisch, 1866; von 
 Recklinghausen, 1871; and by such surgeons as Cheyne, Lister, and Billroth), 
 put the germ theory on a more substantial basis. The work of Pasteur, Koch, 
 and their pupils, in isolating and cultivating bacteria from the lesions of a num¬ 
 ber of diseases and in reproducing identical affections in lower animals by 
 inoculation with pure cultures; the discovery of the Spirocheta obermeieri 
 (spirillum of relapsing fever) in 1873, of the Plasmodium malarice by Laveran 
 in 1880, and other protozoan parasites in the blood, and in various lesions in 
 diseases of the lower animals; and, finally, the studies in general and in specific 
 immunity, established the doctrine on a firm basis by 1890. However, even 
 under an overwhelming mass of evidence, the old ideas died hard. 
 
 In rapid succession, bacteria were identified as the cause of not only wound 
 infection in all its forms, including puerperal infection, but of tuberculosis, 
 gonorrhoea, typhoid fever, cholera, diphtheria, pneumonia, bubonic plague, and 
 other important diseases in man and the lower animals. Yeasts and higher 
 fungi were found in relation to the lesions in a variety of affections. The 
 demonstration of spirochaetse as the causal agents of syphilis, yaws, and infec¬ 
 tious jaundice and the discovery that sub-microscopic viruses are concerned 
 w r ith the causation of certain other communicable diseases are triumphs of 
 recent years. With these findings and the experiments made possible thereby 
 came not only deeper knowledge of natural and acquired immunity against 
 various febrile diseases, and the use of new and more exact methods of diag¬ 
 nosis, but various antitoxic and antimicrobic sera and bacterial vaccines for 
 the prevention and treatment of disease. Long before the germ theory had been 
 rehabilitated by the discoveries of the last 30 years of the nineteenth century, it 
 had been established that cholera (1849) and typhoid fever (1859) are com¬ 
 monly spread by polluted drinking-water; the role of milk as a vehicle for the 
 causative agents of scarlet fever, diphtheria, typhoid fever, and cholera had 
 been discovered before 1885. 
 
 Satisfactory explanations of many of the mysteries of the epidemiology of 
 certain diseases were afforded by the demonstration of the important part 
 played by intermediate hosts, mostly insects, in the spread of certain definite 
 microparasites in man and the lower animals—the cattle tick for that of Texas 
 cattle fever by Theobold Smith and Kilbourne in 1893; the mosquito for that 
 4 
 
44 
 
 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 of the haematozoa of birds by Ross in 1898 and of malaria soon afterwards; 
 the tsetse fly for that of nagana in horses by Bruce in 1894; the mosquito for 
 that of yellow fever by Reed, Carrall, Argamonte, and Lazear in 1900; and the 
 rat flea for that of bubonic plague by the Indian Plague Commission in 1907, 
 and the louse for that of typhus fever by Nicolle in 1909. It has further been 
 shown since 1900 that relapsing fever is spread by ticks, bedbugs, lice, fleas, 
 and biting flies, and that Rocky Mountain spotted fever is spread by ticks. 
 
 The road to these revolutionary discoveries was made easier by the extraor¬ 
 dinary advances in the study of pathological anatomy and experimental 
 pathology during the nineteenth century, which not only established such im¬ 
 portant diseases as typhoid fever, tuberculosis, syphilis, leprosy, pneumonia, 
 dysentery, puerperal fever, wound infection, and other inflammatory affections 
 upon firm anatomical and physiological bases, and pointed to their parasitic 
 origin, but showed the relation of the parasites to the lesions. 
 
 It is a matter of importance in this connection that for the majority of the 
 acute febrile diseases, and among them some of the most dangerous, ranked 
 as contagious by both old and recent authorities—i. e., small-pox, vaccinia, 
 measles, scarlet fever, 1 hydrophobia, influenza, and typhus fever—attempts to 
 discover, in the specific lesions or elsewhere in the body, micro-parasites under 
 conditions satisfying the demands of logic that they act causal roles have 
 completely failed. The positive evidence that these affections are caused by 
 micro-parasites is no stronger now than in the eighteenth century, but the argu¬ 
 ment in favor of such etiology has been greatly strengthened by analogy; that 
 is, in their natural history they present features so similar and in some re¬ 
 spects so closely identical with those that characterize diseases for which proofs 
 satisfactory to the strictest logical requirements for such causation have been 
 established. For the same reason, also, the argument by exclusion has gained 
 some additional weight. 
 
 The discovery that typhus fever is spread by the body-louse not only removed 
 this disease from the class of the typically contagious diseases, but by analogy 
 placed it more definitely in the category with other diseases proved to be 
 caused by micro-parasites transferred from one individual to another by biting 
 insects, for the bites of only those lice that have infested individuals with typhus 
 fever can spread the essential cause of this disease. In the lesions of poliomye¬ 
 litis, classed among the contagious diseases and known only slightly to former 
 generations, but revived in widespread epidemics in recent years, Flexner and 
 his coworkers have discovered minute bodies which seem to be the etiological 
 factors. In yellow fever, classed among the affections reckoned as effluvial in 
 origin, Noguchi has demonstrated a spirochete, which further observations 
 may prove to be the causal agent. 
 
 In their advocacy of the old thesis of contagia viva in the causation of the 
 febrile diseases, Henle and Mitchell argued both by analogy and by exclusion, 
 attempting by the former to establish points of similarity between these diseases 
 and certain affections of plants and lower animals in which micro-organisms 
 had been found under conditions suggesting or even proving a causal relation, 
 and seeking by the latter to show that of the various explanations proposed, 
 
 1 Since this was written the recent highly suggestive work of Dick and Dick and others 
 on the causation and the serum reactions of scarlet-fever has been published. 
 
DEVELOPMENT OF HEALTH DEPARTMENT AND HEALTH LAWS, ETC. 45 
 
 this was the only one consistent with the ascertained facts of the natural his¬ 
 tory of these diseases. At this time the latter mode of argument was the 
 stronger because it was supported by the heavier weight of facts. With the 
 demonstration in rapid succession that a number of diseases, including examples 
 of those classed as contagious and those classed as miasmatic or diluvial, are 
 due to micro-parasites, the analogical argument in favor of like causation of the 
 remainder was correspondingly strengthened. Facts supporting both these 
 lines of argument have become so overwhelming in recent years that there is 
 no escape from accepting the generalization that all the febrile diseases trans¬ 
 missible in continuous series from one individual to another must be caused 
 by the action of living parasites. 
 
 In later chapters a complete list of these diseases, in so far as they have 
 presented themselves in Baltimore, will be given, and the evidence upon which 
 certain of them are held to be transmitted wholely or partly by contact will 
 be submitted to analysis. 
 
 Gradually the term contagion lost and the term infection gained in impor¬ 
 tance. The former, losing its etiological significance, came to mean only a par¬ 
 ticular mode of conveyance, namely, by intimate contact. The group of con¬ 
 tagious diseases became limited to a particular division of infectious diseases. 
 The terms infectious and infection gained new and broader meanings. Infec¬ 
 tious diseases came to include, for clinicians, the whole group of diseases charac¬ 
 terized by fever, increased rapidity of the pulse and respiration, intoxication, 
 with or without local inflammatory lesions; for pathological anatomists the 
 series of degenerations and acute congestions of various organs of the body, 
 notably the heart, liver, kidneys, and spleen, and local inflammatory lesions 
 occurring in febrile affections ; for bacteriologists and hygienists, all the diseases 
 proven or thought to be caused by micro-parasites. 
 
 For the clinical physician a disease is infectious if it is capable of being 
 transmitted from one individual to another by any means whatsoever; it is 
 contagious if it can be, or usually is, carried by contact with the sick or their 
 immediate environment. The “ droplet infection ” of Fliigge, by which is 
 meant the transmission from one person to another of micro-organisms attached 
 to fine drops of moisture (saliva,, mucus, pus) propelled from the mouth 
 and nose in the acts of talking, coughing, and sneezing, belongs under the 
 latter heading. The organisms are thus thrown so short a distance that, in 
 effect, this method of transference may be regarded as so slightly removed 
 from kissing or other forms of actual touch, as to fall well within the concep¬ 
 tion of “contact.” For the clinician, the pathologist, and the bacteriologist, a 
 person or an animal is “ infected ” after receiving a particular variety of 
 germ in numbers sufficient to cause disease. But, for the bacteriologist “ in¬ 
 fected ” retains its original meaning of “ spoiled,” “ tainted,” “ corrupted,” in 
 the special sense that a germ capable of multiplication comes in contact with 
 a substance of any kind, as nutrient media, an instrument or utensil. It has 
 much the same significance to the surgeon. 
 
 Probably the first clear-cut definition of the term infectious disease in the 
 modern sense was given by Professor William H. Welch in his lectures at the 
 Johns Hopkins Hospital in the spring of 1890: “ An infectious disease is any 
 disease caused by the entrance into and multiplication within the body of 
 
46 PUBLIC HEALTH ADMINISTRATION', ETC., IN BALTIMORE 
 
 pathogenic micro-organisms.” This definition, as Professor Welch pointed out 
 at the time, excludes a large group of affections caused by the invasion of the 
 body by macroscopic parasites of which the worms are examples. For such 
 diseases, there is a tendency to use the term infestion. Thus in modern usage, 
 infection has to do with causation alone and omits all consideration of modes 
 of communication, while contagion deals only with a particular mode of 
 transmission, i. e., by contact, and has nothing to do with ultimate causation. 
 Some of the infectious diseases are typically contagious, but many are not. 
 With the adoption of a new meaning for infectious, its synonym, miasmatic, 
 fell into disuse. Fomites, from being the fuel itself carried by the absorbent 
 material, came to signify the material which conveys the fuel, a complete 
 reversal of meaning. 
 
 To avoid the great confusion of meanings attending the use of the terms 
 contagious and infectious as applied to the febrile diseases, especially among 
 the older generation of physicians who could not readily follow the rapid de¬ 
 velopment of the new science of micro-parasitology in which they had had no 
 training (and this group included many health officers), the terms communi¬ 
 cable and transmissible came into use about the beginning of the twentieth cen¬ 
 tury to include the group of affections caused by invasions of the body by 
 vegetable or animal parasites. 
 
 The idea that emanations from sewers were efficient causes of diseases natu¬ 
 rally followed from the conception that certain epidemic diseases were due 
 to the effluvia arising from the putrefaction of dead organic material. There¬ 
 fore, the emanations from either open sewers or the traps of closed sewers, 
 or from privies and cesspools were regarded as particularly dangerous. With 
 the development of toilets, wash-basins, and bath-tubs in houses connected 
 with sewers, it was not unnatural that cases of febrile illness developing in 
 these houses were attributed to sewer-gas emanating from the sewers through 
 untrapped or improperly trapped connections. The acute febrile diseases 
 thought to be thus caused were at first either those generally acknowledged to 
 be infectious or miasmatic, such as the malarial-fever group, or those included 
 in this class by some and among the contagious diseases by others, such as 
 dysentery, typhoid fever, typhus fever, and diphtheria. To the latter group the 
 term miasmatic-contagious was often applied. As a result of this conception 
 plumbing construction and plumbing inspection arose to such great impor¬ 
 tance in health-department administration. 
 
 From the foregoing it is clear why, in the first health ordinances, clear-cut 
 distinctions were made between the function of controlling disease through the 
 management of persons and their immediate environment and through the 
 general environment. To the board of health were assigned questions involv¬ 
 ing personal hygiene and to the city commissioners the control of general 
 sanitation. 
 
Chapter IV. —Evolution of Public Health Laws. 
 
 I. Baltimore Town. 
 
 II. Baltimore City: The two fundamental ordinances of 1797 —Ordinance 
 No. 11 and subsequent amendments and additions dealing with the organi¬ 
 zation of the health department and the duties and powers of health 
 officials, the reporting and isolation of cases of communicable diseases within 
 the city, quarantine of the port; Hospitals controlled by the city, and the 
 registration of births and deaths, and of physicians, midwives, and under¬ 
 takers; Ordinance No. 15 and subsequent amendments and additions dealing 
 with nuisances, namely, general sanitation on public domains—Street clean¬ 
 ing, garbage, night-soil collection and disposal, food control—Sanitation on 
 private domains—Privies, cesspools, night soil, standing water and decaying 
 materials, cellars, manufactories injurious to health, garbage, habitations, 
 plumbing, foods. 
 
 III. State of Maryland: Contagious and infectious diseases; Vaccina¬ 
 tion; Medical practice; Registration and licensing of midwives; Pharma¬ 
 cists; Nurses, plumbers, undertakers, and barbers; Registration of births 
 and deaths; Lunacy commission; Child and other labor laws; General 
 nuisances; Foods; Building inspection. 
 
 I. BALTIMORE TOWN. 
 
 The records of public-health activities in Baltimore before the elevation of 
 Baltimore Town into Baltimore City on January 1, 1797, are scanty. During 
 the era of Baltimore Town, the powers of local self-government granted by the 
 legislature were comparatively restricted. There is no record of the existence 
 of anything approaching a separate organized body with duties and powers in 
 connection with public health in the early days of Baltimore Town. Some 
 sort of control over nuisances of the commoner sort was exercised by the town 
 commissioners and by certain special commissioners, as the commissioners for 
 paving streets, for instance. In 1745, an act of the commissioners proscribed the 
 running at large of geese and swine in the town. According to Quinan, the 
 town commissioners passed the following resolution in 1750: 
 
 “ Whereas, several persons permit stinking fish and dead creatures or carrion to lie 
 on their lots, or in the street near their doors, which are a very offensive nuisance and 
 contrary to Acts of Assembly, the Commissioners, therefore, order the clerk to put up 
 advertisements to inform such persons that they are to remove the same. 
 
 “ Resolved, That Dr. Wm. Lyon be a committee of one to enforce the same.” 
 
 In 1793, when yellow fever was prevalent in Philadelphia, Governor Lee 
 appointed Dr. John Ross and Dr. John Worthington as quarantine physicians, 
 the former to regulate quarantine by sea and the latter by land. In 1794, Gov¬ 
 ernor Lee appointed Dr. Thomas Drysdale as an additional quarantine phy¬ 
 sician for Baltimore. On July 8 of that year, Drs. Ross, Worthington, and Drys¬ 
 dale, by orders of the governor, stopped all vessels at the quarantine station 
 established below Whetstone Point. These acts of the governor were carried 
 out under Acts of the Assembly in 1766, 1769, 1777, and 1784, empowering 
 the governor to establish quarantine under threatened invasion of pestilen¬ 
 tial diseases. 
 
 47 
 
48 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 According to Quinan (9) and Griffith (3), a committee on health, con¬ 
 sisting of seven members was appointed, probably by the town commissioners, 
 in 1794. Quinan speaks of this health organization in 1794 as the board of 
 health and records that on April 24, 1795, a new board of health was elected, 
 which adopted rules and regulations of quarantine on May 7 and urged the 
 citizens to aid in enforcing them. On May 7, 1795, the legislature passed an 
 act empowering the appointment of a health officer for the port of Baltimore, 
 and on July 29, the board of health imposed a quarantine on all vessels from 
 South America or the West Indies and, on August 16, ordered that no hides be 
 landed from vessels within the town limits. 
 
 It would appear that the State quarantine officers acted harmoniously in 
 concert with the newly appointed board of health of Baltimore Town, for 
 Quinan records that on August 15, 1794, Dr. Boss publicly defended the board 
 of health which had been charged with negligence in allowing the admission 
 of cases of yellow fever. 
 
 All these activities and measures grew, largely at least, out of the serious 
 yellow-fever epidemics of the time. The details of the quarantine system have 
 not been preserved, but it is probable that they were almost identical with 
 those provisions in the first public-health ordinance of Baltimore City, passed 
 on April 7, 1797. It is probable that the board of health of 1795 continued to 
 function until it was relieved by the new public-health organization provided 
 for in Ordinance 11, 1797. 
 
 When Baltimore Town became Baltimore City, on December 31, 1796, its 
 public health organization, therefore, consisted of a board of health of seven 
 members, empowered to pass and enforce quarantine regulations, a health 
 officer of the port, and a small hospital at Hawkins’ Point for the reception of 
 cases of “ pestilential diseases.” Such powers over nuisances and general sani¬ 
 tation as existed had been exercised by the town commissioners. 
 
 II. BALTIMORE CITY. 
 
 Soon after the organization of the new city government of Baltimore in 1797, 
 two health ordinances were passed, one dealing particularly with the control 
 of diseases through persons and their effects, the other with the control of 
 nuisances and other matters of general sanitation. Upon these two basic ordi¬ 
 nances has been modeled practically all of the subsequent local health legisla¬ 
 tion, much of which has been enacted in the form of supplements. The gen¬ 
 eral principles of these ordinances will be discussed separately. It is to be 
 noted that they are of a broad and general, rather than of a narrow and specific, 
 character. 
 
 The opening declaration of general principles of Ordinance 11, 1797, is 
 important and shows that the intent of the authorities was to prevent the ori¬ 
 gin, introduction, and spread of “ pestilential and other infectious diseases.” 
 The placing of the powers and duties of the health department under nine 
 commissioners of health was probably done with the intention of having all 
 sections of the city fully and forcibly represented. The hospital at Hawkins’ 
 Point had been established some years before as a yellow-fever hospital in 
 connection with the quarantine instituted for that purpose. In the second 
 section of the ordinance are enumerated the various kinds of nuisances which 
 
DEVELOPMENT OF HEALTH DEPARTMENT AND HEALTH LAWS, ETC. 49 
 
 it was thought important to attempt to control, and under this heading fell all 
 of the items included under the head of general sanitation of that date. It 
 must be regarded as a declaration of the general principles of sanitation. It did 
 not, however, make it the duty of the board of health to prevent or correct 
 such nuisances, this duty being left to the city commissioners as provided in 
 Ordinance 15. Sections 3 to 9, inclusive, and section 11 deal entirely with the 
 quarantine of persons and goods entering by land or sea. The intent of these 
 provisions was to prevent the introduction of any “ contagious or pestilential 
 disease ” from over seas. For this purpose, there was provided a paid quaran¬ 
 tine health officer to visit vessels before their near approach to the harbor. 
 Power was granted to remove those ill with contagious diseases to the hospital 
 at quarantine, and communication between quarantined vessels and the city was 
 forbidden. There were, however, no provisions specified for cleaning vessels 
 or disinfecting cargoes at the quarantine station. The landing of damaged 
 hides, damaged coffee, and other damaged goods within 3 miles of the city 
 was interdicted. It will be noted that the quarantine applied to all vessels 
 from over seas and to such vessels as came from suspected places in this 
 country, and that the quarantine period was for only 7 months of the year. 
 Vessels were not to be indiscriminately detained for the usual 40 days, but 
 only long enough to satisfy the quarantine physicians that they were not 
 dangerous. In comparison with the elaborate, strict, and inelastic quarantines 
 of the Mediterranean ports, of England, and of certain American ports, nota¬ 
 bly New York and Philadelphia, these regulations were mild. In common 
 with the practice at these ports, however, the belief was recognized that dam¬ 
 aged goods bore direct relation to the spread of the diseases the introduction 
 of which it was sought to prevent. It would appear that the entry of ordinary 
 goods not subject to putrefaction was not considered dangerous. There is 
 reason to think that the quarantine was chiefly against yellow fever and small¬ 
 pox and perhaps typhus fever and that the plague, so feared by Europeans and 
 which had never invaded the United States up to this time, was not considered 
 likely to be introduced into Baltimore. This ordinance gives no indication that 
 the city government at that time had any idea of attempting to combat by 
 restrictive measures the spread of any other disease established within the 
 city than the malarial fevers. 
 
 Ordinance 15, 1797, which deals practically with those nuisances mentioned 
 in section 2 of Ordinance 11, is to be regarded as complementary to that or¬ 
 dinance, but the powers granted under it were to be exercised by the city 
 commissioners and not by the board of health. This ordinance provided for 
 the cleaning of sidewalks by abutting property owners, and interdicted the 
 placing of household or manufactory refuse upon the public streets and the 
 creation of offensive nuisances of various kinds. It directly aimed at the 
 prevention of the stagnation of water and the decomposition of vegetable 
 and animal matter upon either private lots or public highways, and, finally, it 
 provided for the removal of household refuse and for the cleaning of the 
 streets at the expense of the city. 
 
 These two basic health ordinances of the City of Baltimore have undergone 
 many modifications and amplifications in various details in the 123 years 
 since they were written. Considerable changes took place between 1797 and 
 1824, a period marked by experimentation and shifting of opinion. The 
 
50 
 
 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 changes in the health ordinances were probably greatly influenced by the de¬ 
 velopment of vaccination against small-pox and by the conclusion reached 
 after much experience and debate that yellow fever is not contagious and 
 not necessarily imported, but of local origin. To avoid confusion and useless 
 repetition, the changes in and additions to these basic ordinances will be 
 presented as concisely as possible under the various subjects which they con¬ 
 cern and in the order of their appearance in the field of the health depart¬ 
 ment’s activities. 
 
 Ordinance 11, Approved April 7, 1797. 
 
 An ordinance to preserve the health of the city, and to prevent the intro¬ 
 duction of pestilential and other infectious diseases into the same. 
 
 “ Whereas it is found necessary in all large cities, particularly those bordering on the 
 seas, to establish such laws and regulations as may tend to preserve the health of the 
 inhabitants. And whereas it is of the utmost importance to the commerce of this State, 
 that the health, welfare and prosperity of this city be preserved, and that the origin, 
 introduction and spreading of pestilential and other infectious diseases, be prevented. 
 
 “ Therefore be it enacted and ordained by the mayor and city council of Baltimore, 
 that nine persons be appointed commissioners of health, to aid and assist the health 
 officer for the time being, in carrying the provisions of this ordinance into effect, and 
 that the said commissioners shall have the direction and government of the hospital 
 established on Hawkins’ Point; shall be authorized, and they are hereby authorized 
 and empowered to establish such rules and regulations for the government of the said 
 hospital, as to them may appear proper and necessary; to contract with a suitable person 
 to superintend the same, and for as many assistant physicians and nurses as circum¬ 
 stances may at any time render necessary; to provide medicine and all other articles 
 which may be necessary for the comfort and accommodation of the sick; to provide 
 for a ready communication between the hospital and Fort Whetstone Point or the city, 
 and to do all other matters and things, which by this or any other ordinance they are 
 or may be required to do. 
 
 “ Be it enacted and ordained, that all ponds of stagnant water, all cellars and founda¬ 
 tions of houses, whose bottoms contain stagnant and putrid water, all dead putrefied 
 animals lying about the docks, streets, lanes, alleys, vacant lots or yards, all privies 
 that have no wells sunk under them, all grave yards, tallow chandleries, tanneries, sugar 
 boilers, skin dressers, dyers, glue boilers, and slaughter houses not properly regulated; 
 all docks whose bottoms are alternately wet and dry by the ebbing and flowing of the 
 tide, all accumulation of filth in the streets, lanes, alleys and gutters thereof, all accu¬ 
 mulations of vegetable and animal substances, undergoing a putrefactive fermentation, 
 are hereby declared common nuisances, productive of offensive vapors and noxious 
 exhalations, the causes of diseases, and ought to be restrained, regulated and removed. 
 
 “ Be it enacted and ordained, in order the more effectually to prevent the introduc¬ 
 tion of pestilential and other infectious diseases into the city, that at any time when 
 the mayor of the city shall receive satisfactory information of the existence of any 
 pestilential or other fatal disease, in any place on the continent, with which the citizens 
 of Baltimore may have communication or connection, the mayor may and is hereby 
 authorized to issue a proclamation, forbidding the entrance of all persons coming from 
 such infected places into the city or within three miles thereof, and the citizens from 
 having any communication with them, for at least fifteen days; provided he, she, or they 
 cannot produce an approved certificate of their absence from such place for at least 
 fifteen days previous thereto; and every person wittingly and knowingly offending 
 against the directions of the said proclamation shall forfeit and pay one hundred dollars 
 for every such offence, one-half to the informer and the other half for the use of the city. 
 
 “ Be it enacted and ordained, that the health officer for the time being shall, and he is 
 hereby, directed to visit all vessels coming from beyond the seas, and all other vessels 
 coming from suspected places, in the months of April, May, June, July, August, Septem¬ 
 ber, October, and November, and where it shall appear necessary, detain the same at or 
 
DEVELOPMENT OF HEALTH DEPARTMENT AND HEALTH LAWS, ETC. 51 
 
 below the fort till he hath made two or more visits on board; and if it shall appear to 
 such health officer that a further detention be necessary, he shall oblige the same to 
 perform a quarantine not exceeding twenty days, and in all such cases the health of¬ 
 ficer shall give a certificate to the captain or master of the vessel, signed with his 
 name, expressing the number of days the said vessel is to ride quarantine, and at or 
 before the end of each quarantine the health officer is hereby enjoined to make a second 
 visit to the said vessel; and should it appear to him that a further quarantine is neces¬ 
 sary, he is hereby authorized to enjoin the same for any number of days not exceeding 
 ten. 
 
 “ Be it enacted and ordained, that if the master or other person having charge of 
 any vessel bound to the port of Baltimore, having on board any person or persons dis¬ 
 ordered with any contagious disease, or coming from any sickly port or place without 
 a clean bill of health, shall bring his vessel or suffer or permit the same to be brought 
 nearer to the port of Baltimore than Hawkins’ Point, or shall land or bring on shore, 
 or cause or suffer to be landed or brought on shore, any such infected persons, or any 
 part or parcel of their goods or effects, or any other goods, until he has obtained a 
 license or permit so to do from the health officer or his assistant, such master or any 
 other person having charge of such vessel shall forfeit and pay for every such offence the 
 sum of one thousand dollars, for the use of the city. 
 
 “ Be it enacted and ordained, that if any master or other person having command of 
 any vessel at the time of inquiry by the aforesaid health officer or his assistant shall 
 have on board any person infected as aforesaid, and shall knowingly conceal the same, or 
 shall not make a just and true discovery to the said health officer or his assistant of 
 the sickly and disordered state of all and every person on board, from the time the 
 said vessel departed from the port or place from whence she last sailed to the time of 
 said inquiry, and of all other particulars necessary for the said health officer or his 
 assistant to know, respecting the premises, such master, or other person having com¬ 
 mand of such vessel, shall forfeit and pay for every such offence the sum of three 
 hundred dollars, for the use of the city. 
 
 “ Be it enacted and ordained, that during the detention of any vessel at or below 
 the fort, by the health officer, or during the time of her being ordered to perform quar¬ 
 antine by him, it shall not be lawful for any person on board such vessel to come on 
 shore and have communication with any person, or for any person to go on board such 
 vessel without the permission of the health officer in writing; every person offending 
 against the provisions of this clause shall forfeit and pay the sum of twenty dollars, to 
 be applied for the use of the city. 
 
 “ And be it enacted and ordained, that if any pilot shall conduct any vessel above 
 Hawkins’ Point, having on board above thirty persons, being passengers or servants 
 (and it is hereby, declared to be the duty of each pilot to make due inquiry thereof) 
 such pilot shall forfeit and pay one hundred dollars for the use of the city, and if any 
 pilot shall have knowledge that there is on board any vessel that he undertakes to pilot, 
 any persons distempered with the plague, or any malignant contagious disease, and it 
 is hereby declared to be his duty to make due inquiry thereof, and shall pilot such 
 vessel above Hawkins’ Point, he shall forfeit one hundred dollars for the use of the 
 city; and such pilot shall be disqualified to act as pilot for one year; and if any pilot 
 shall have knowledge that there is on board any vessel that he undertakes to pilot, 
 any person distempered as aforesaid, and it is declared to be his duty to make due 
 inquiry thereof, and shall conceal the same from the aforesaid health officer or his 
 assistant, such pilot shall forfeit one hundred dollars, for the use of the city, and such 
 pilot shall be disqualified to act as pilot for one year. 
 
 /( And be it enacted and ordained, that the commissioners of health shall watch over 
 the health of the city; and aid and assist the health officer in the discharge of his 
 duty, and carry into effect the provisions of this ordinance, and shall meet at the court 
 house or some other place in the said city, on the first Monday in the months of May, 
 June, July, August, September, October and November, or as often as occasion may 
 require for the purposes aforesaid, collect and receive every possible information of the 
 healthiness of the same; and the health officer is hereby required then and there to 
 meet them, with such evidences of facts relative to his appointment as may have come 
 to his knowledge; and the said commissioners of health shall give all necessary assis- 
 
52 
 
 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 tance to the health officer in the execution of his duty, cause all persons actually laboring 
 under infectious diseases (and not otherwise provided for) to be removed to the hos¬ 
 pital on Hawkins’ Point, or elsewhere, distant from the city at least three miles, and 
 provide for the infected such meats, drinks, bedding, and clothing as may be absolutely 
 necessary or ordered by the health officer, and with the advice of the health officer, or 
 other practicing physician or physicians, whom they may consult, may take such fur¬ 
 ther measures in discharging the trust confided to them, as may appear reasonable and 
 proper. 
 
 “ Be it enacted and ordained, that the health officer or the commissioners of health 
 shall be, and they are hereby, authorized to prevent the landing of any damaged hides, 
 damaged coffee, or other damaged goods from on board any vessel whatever, on any 
 wharf in the city, or within three miles thereof, which in their judgment would en¬ 
 danger the health of the inhabitants. And every person wittingly and knowingly landing 
 any of the same articles, contrary to the provision aforesaid, shall forfeit and pay for 
 every such offence one hundred dollars, half to the informer and the other half for 
 the use of the city. 
 
 “ Be it enacted and ordained, that the commissioners of health may appoint a clerk, 
 and allow him a reasonable compensation for his services, who shall keep fair minutes 
 of their proceedings, and all necessary expenses incurred by them in the discharge of 
 the duties herein required, which shall be defrayed by the corporation.” 
 
 ORGANIZATION OF THE HEALTH DEPARTMENT. 
 
 COMMISSIONERS OF HEALTH AND PRINCIPAL ASSISTANTS. 
 
 The ordinance of March 20, 1801, reduced the number of commissioners of 
 health from 9 to 5, 2 of whom had to come from that part of the city lying 
 east of Jones Falls. The city was divided into five districts, one of which was 
 allotted to each commissioner for supervision. The commissioners were re¬ 
 quired to meet as a board of health at least once a week in the months of 
 April, May, June, July, August, September, and October for the purpose of 
 communicating and receiving all possible information relative to the health 
 of the city and to advise and consult with each other respecting its preserva¬ 
 tion. 
 
 The number of commissioners of health was reduced to 4 by the ordinance of 
 March 22, 1803, and their authority over nuisances on private domains, in¬ 
 cluding docks, was considerably increased. 
 
 According to the ordinance of March 17, 1808, the position of health (quar¬ 
 antine) officer was abolished, and the number of commissioners of health 
 was reduced to 2. 
 
 The powers and duties of the city commissioners and the commissioners of 
 health were united b}^ the ordinance of March 22, 1809, and the new com¬ 
 missioners were given the power to execute all the previously passed ordinances 
 regulating the duties and powers of the two commissions. By this act, the con¬ 
 trol of nuisances and matters of general sanitation were placed under the 
 health department. 
 
 In the ordinance of March 25, 1814, it was provided that the number of com¬ 
 missioners be increased from 2 to 3. 
 
 By resolution of the city council passed December 4, 1817, the commissioners 
 of health, with other departments of the city government, were required to 
 make annual reports to the council “ of the state of the several subjects com¬ 
 mitted to their charge and to suggest such alterations and amendments, if any, 
 as may be found by experience necessary in the ordinances connected with 
 their different departments.” 
 
DEVELOPMENT OF HEALTH DEPARTMENT AND HEALTH LAWS, ETC. 53 
 
 The ordinance of February 29, 1820, provided for a consulting physician, who 
 with the three commissioners constituted a Board of Health, which was to 
 meet biweekly from March 1 to November 1 and bimonthly from November 1 
 to March 1. The city was divided into three sanitary districts, each under the 
 supervision of a commissioner, who was required to inspect at least once every 
 two weeks from March 1 to November 1 all the streets, alleys, lanes, wharves, 
 warehouses, cellars, yards, lumber yards, lots, docks, and all other places he 
 might think necessary in his district. Each commissioner was required to re¬ 
 port to the board of health on the general state of his district once in every two 
 weeks and to enforce all the laws and ordinances in relation to health, including 
 the abatement of nuisances and the duties in relation to the health department 
 usually performed by the city commissioners, and all others that might be 
 required of him by the board of health or the ma} r or. 
 
 The duties of the consulting physician were to give the mayor and other city 
 authorities such professional advice and information as they required, with 
 a view to the preservation of the public health, to inquire into the health of the 
 city, and when he should hear of the existence of any malignant, pestilential, 
 or contagious disease to investigate such report and ascertain as correctly as 
 possible the causes which produced said disease, to report this information to 
 the board, and to suggest measures to arrest its progress, reporting to the 
 mayor, the board of health, or the commissioners of the districts, as the case 
 required, every circumstance likely to endanger the health of the city. 
 
 The salary of the commissioners was $600 each, and that of the consulting 
 physician was $400. 
 
 The ordinance of March 1844 abolished the positions of the commissioners 
 of health and of the consulting physician and assigned the duties of the former 
 to the city commissioners and of the latter to the health or quarantine officer. 
 
 By the ordinance of May 2, 1845, the health department was again reorgan¬ 
 ized, this time with one commissioner of health and a city physician, who 
 with the health officer or quarantine physician constituted a board of health 
 to meet biweekly throughout the year with the city physician as presiding of¬ 
 ficer. The commissioner of health was to attend to all the duties of the health 
 office and was to be present at the office of the board from 9 a. m. to 1 p. m. 
 every day, Sundays excepted. He was to keep a faithful record of all matters 
 relating to the health of the city, to receive all reports from the police of¬ 
 ficers and others so far as they referred to the duties of the health depart¬ 
 ment, to enforce all ordinances for the preservation of health, and to decide 
 all appeals from the reports of the police officers by a personal examination of 
 the premises in all cases of dispute. It was the duty of the city physician to 
 make a circuit of observation once every week to every part of the city and its 
 environs, in which location or any collateral circumstance might be a cause 
 of disease, and in all cases where he discovered the existence of any morbific 
 agent, the presence of which might prove dangerous to the health of the city, 
 he was to cause any ordinance in existence for its correction to be enforced. 
 If no competent ordinance existed, he was to make a full report to the mayor, 
 accompanied with his opinion concerning the particular action to be taken. It 
 was also his duty to make diligent inquiry into all cases of malignant, infec¬ 
 tious, or contagious diseases which might occur and to cause immediate mea¬ 
 sures to be taken to arrest their progress and generally to notice all things 
 
54 
 
 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 that related to the preservation of the health of the city. It was the duty of 
 the health officer, in addition to such duties as were required of him by exist¬ 
 ing ordinances, to attend such meetings of the board of health as he might 
 be requested to attend either by the mayor or by the president of the board, to 
 inform the board of anything demanding the attention of the department, and 
 to advise with the city physician on all subjects particularly “ appertaining to 
 the sanitary of the maritime.” The police officers were required to execute all 
 orders of the board of health or any member thereof, so far as they referred 
 to the preservation of the health of the city. They were to make daily in¬ 
 spections in their wards and report every morning to the commissioner of 
 health and to enforce all ordinances for the preservation of health within the 
 city. The salary of the commissioner of health was $800 and that of the city 
 physician $400 per annum. 
 
 The ordinance of September 4, 1846, retransferred to the board of health 
 all of the duties of the city commissioners. 
 
 The ordinance of February 28, 1861, combined the office of city physician 
 and commissioner of health and provided for an assistant commissioner of 
 health, who, with the commissioner of health, would constitute the board of 
 health. The duties of the commissioner of health were unchanged. Those of 
 the assistant commissioner were to keep a faithful record of all reports and 
 other matters of the department, and, in case of sickness or absence of the com¬ 
 missioner or when directed by the mayor, to perform the duties assigned to 
 the commissioner. The duties of the marine hospital or quarantine physician 
 were unchanged. 
 
 By the ordinance of May 23, 1882, the health commissioner was authorized 
 to order all post-mortem examinations and to contract with two surgeons to 
 do this work. Later, provision was made for a post-mortem physician and one 
 assistant. 
 
 The mayor was made member ex-officio of the board of health, the remain¬ 
 ing members being unchanged, according to the ordinance of April 14, 1888. 
 The board of health was required to meet daily throughout the year. The 
 commissioner of health was also made register of vital statistics. 
 
 The ordinance of May 7, 1894, empowered the commissioner of health to 
 appoint a chemist and three food inspectors. 
 
 By an ordinance of 1896, the commissioner of health was authorized to 
 appoint a bacteriologist and to establish separate chemical and bacteriological 
 laboratories in the health department. 
 
 According to a section of the revised charter of Baltimore City of 1900, 
 the health department was made a subdivision of the department of public 
 safety, consisting of the board of fire commissioners, the commissioner of 
 health, the inspector of buildings, the commissioner of street cleaning, and 
 the president of the board of police commissioners, ex-officio. The board of 
 public safety was for consultation and advice and had no power to direct or 
 control the duties or the work of any subdepartment. Section 71 of this char¬ 
 ter made the commissioner of health the second sub-department of public 
 safety. The board of health was done away with, and the commissioner of 
 health was given complete charge of the health department, with all of the 
 duties and powers formerly exercised by the board. The commissioner of 
 
DEVELOPMENT OF HEALTH DEPARTMENT AND HEALTH LAWS, ETC. 55 
 
 health must be a physician of five years* experience and in active practice at 
 the time of his appointment. He may appoint two assistant commissioners of 
 health, a medical examiner, and an assistant medical examiner, and a reason¬ 
 able number of clerks and subordinates, and fix their compensation. 
 
 Since 1900, it has been the practice to establish new positions in the health 
 department through the annual ordinances of estimates, instead of by spe¬ 
 cial ordinances. 
 
 VACCINE PHYSICIANS AND HEALTH WARDENS. 
 
 By resolution of the city council, December 17, 1821, Drs. Birkhead, Coulter, 
 Allender, Jennings, and Baker were requested to act as a commission to select 
 and appoint a physician for each of the six districts of the city, “ whose duty it 
 shall be to obtain a full and exact account of all persons whatever in said dis¬ 
 tricts respectively, who have not been vaccinated or had the small-pox, to vac¬ 
 cinate gratis all persons not competent in their opinion to pay for it, and to 
 use their utmost efforts to induce all others to be immediately vaccinated aa 
 a measure loudly called for by the advice of the faculty and by public neces¬ 
 sity.** The vaccine physicians were required “ to keep an exact register of all 
 their vaccinations and the other material occurrences relative thereto, and to 
 report the same as approved by the aforesaid board or commission to the mayor 
 and city council, and to obey all instructions which said board may think proper 
 to give them, or either of them, with a view to effect the full and complete vac¬ 
 cination of every individual within their respective districts.** These district 
 physicians received a salary of not over $200 each and in proportion to the 
 nature, extent, and efficiency of their sendees. These provisions were made at 
 the suggestion of the Medical and Chirurgical Faculty at the time of a severe 
 small-pox epidemic and were temporary. 
 
 In 1824, the office of vaccine physician was made permanent, and in this 
 year the commissioners of health were empowered to divide the city into four 
 districts and to appoint for each district a vaccine physician at the salary of 
 $100, “ for the purpose of extending the benefits of vaccination to the indi¬ 
 gent of our city.** 
 
 By the ordinance of March 11, 1853, the vaccine physicians became health 
 wardens, and in addition to their former duties they were given the general 
 supervision of the health of their wards. They were to look for and report all 
 nuisances dangerous to health, and “ whenever any disease of a contagious char¬ 
 acter shall manifest itself in their respective districts, they shall, under the 
 direction of the board of health, use such means as the nature of the case may 
 demand to arrest its progress.** The ordinance of June 9, 1864, provided for 
 a vaccine physician for each two contiguous wards, who should vaccinate in 
 his wards all such persons pointed out to him by any member of the board 
 of health as susceptible to small-pox contagion and whose duty would be to 
 visit each dwelling-house in his wards and to vaccinate every person presented to 
 him for that purpose. He was also required to keep an office hour to vaccinate 
 all persons calling upon him for such service. 
 
 By an ordinance passed October 24, 1882, the commissioner of health was 
 given power to enforce at his discretion the vaccination of all persons not 
 previously vaccinated, residing within the city, and the vaccination of any per¬ 
 son in any infected district. Parents and guardians were required to cause 
 
56 
 
 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 their children to be vaccinated before attaining 1 year of age and revaccinated 
 after 5 years from the last vaccination whenever the commissioner of health 
 should order it. It became the duty of the vaccine physicians or health wardens 
 to effect or oversee the carrying out of these provisions. 
 
 Section 71 of the revised charter of Baltimore City of 1900 provided that 
 the commissioner of health shall appoint a vaccine physician for every ward 
 of the City of Baltimore, who shall be a resident of the ward for which he 
 may be appointed, for the purpose of vaccinating all such persons in his ward 
 as may be designated by the commissioner or the assistant commissioner of 
 health as susceptible to small-pox contagion. All of these vaccine physicians 
 shall act as health wardens for their respective wards, generally supervise the 
 health of their wards, and report to the commissioner of health any nuisance 
 which in their opinion is or may become a source of disease, using under the 
 direction of the commissioner of health such means as the nature of the case 
 may demand to arrest its progress. 
 
 Inspectors .—By an ordinance of 1797, an inspector was appointed for the 
 examination of salted provisions imported into and exported from the City of 
 Baltimore. The ordinance of October 22, 1883, provided for the appointment 
 of an inspector of plumbing for sanitary purposes to work under the super¬ 
 vision of the board of health. The inspector was to be a practical plumber, skill¬ 
 ful and well trained in matters pertaining to the sanitary regulations concern¬ 
 ing plumbing work. All plumbing work was to be subject to the supervision of 
 the inspector of plumbing and performed in no other way than in strict con¬ 
 formity to such orders and directions as might be prescribed by the inspector 
 of plumbing with the approval of the board of health. 
 
 Four additional sanitary inspectors were provided for the twenty-first and 
 twenty-second wards by the ordinance of June 19, 1888. 
 
 Three inspectors of food were to be appointed, according to the ordinance 
 of May 16, 1894, for the purpose of obtaining samples of milk and all other 
 food products, the qualities of which were to be determined by chemical or 
 microscopical examination. 
 
 Under Section 68 of the revised city charter of 1900, the commissioner of 
 health was given the power to appoint a reasonable number of sanitary inspec¬ 
 tors for the city, not exceeding 15; all inspectors and analysts of bakeries, bake- 
 shops, candy factories, confectioneries, or other places for the manufacture of 
 similar food products, for the purpose of ascertaining their sanitary condi¬ 
 tions and cleanliness and the purit}^, healthfulness, and wholesomeness of the 
 ingredients used in manufacture, and all inspectors and analysts for the proper 
 inspection of milk, or any and all other food products offered for sale in the 
 City of Baltimore. 
 
 THE REPORTING AND ISOLATION OF CONTAGIOUS AND INFECTIOUS 
 
 DISEASES WITHIN THE CITY. 
 
 The ordinance of 1797 made no allusion to the reporting of cases of diseases 
 within the city. By the ordinance of March 20, 1801, practising physicians 
 were “ invited ” to inform the commissioners of health of the state of health 
 of the city and to advise them in all matters relating to the prevention of conta¬ 
 gious diseases. The commissioners of health were given full power to remove 
 
DEVELOPMENT OF HEALTH DEPARTMENT AND HEALTH LAWS, ETC. 57 
 
 any person afflicted with a contagious disease dangerous to the community 
 to a hospital or other place and to prevent any kind of communication with 
 the affected house or family except by physicians, nurses, or persons necessary 
 to carry medicines and provisions. It was made the duty of the commissioners, 
 when a contagious disease was discovered in the city, to advertise the fact and 
 to caution citizens against communication with the infected neighborhood. 
 When such disease threatened to become general, they could advise the inhabi¬ 
 tants (of an infected district) to remove to quarters provided for their recep¬ 
 tion—the poor to be supported at public expense. 
 
 The ordinance of February 10, 1820, provided that “ it shall be the duty 
 of all and each of the practising physicians in the city of Baltimore, whenever 
 any case of malignant, pestilential, or contagious fever shall happen within the 
 circle of their practice, forthwith to report the same to the mayor or the board 
 of health.” The penalty for non-compliance was $100. This section was, 
 however, omitted in a revision of this ordinance 19 days later, on February 
 29, 1820. One of the sections of this ordinance required that every keeper of 
 a tavern or boarding or lodging-house should report cases of illness, occurring 
 between the first of March and the first of November, in seafaring men or other 
 sojourners, and masters of vessels lying in the harbor were forbidden to remove 
 any sick person therefrom without permission. 
 
 In 1821, the board of health was required by ordinance to cause all districts 
 in which yellow fever was confirmed and beyond control to be fenced in and 
 guarded by sentinels. 
 
 By the ordinance of April 25, 1834, physicians were requested to report 
 to the board of health within 24 hours all cases of small-pox and varioloid 
 coming to their knowledge, and the commissioners of health were required, 
 whenever they met with a case of small-pox which had not been so reported, 
 to publish in the newspapers the name of the physician who had failed or 
 refused to report it, but in 1838, the threat was omitted. In the code of 1869, 
 even the request to report cases of small-pox was eliminated. 
 
 Compulsory reporting of “ contagious and infectious ” diseases on a limited 
 scale by practising physicians went into effect after the passage of the ordinance 
 of October 24, 1882, which required that “ every physician shall report to 
 the commissioner of health, in writing, upon blanks to be furnished by 
 said commissioner, every person having small-pox, cholera, yellow fever, malig¬ 
 nant diphtheria, or scarlet fever, and varioloid, and his or her place of dwelling, 
 and name, if known; such report to be made within 24 hours after the first 
 visit, if such report were not previously made by some other physician.” By this 
 ordinance, physicians were required also to report to the commissioner of health 
 the deaths of any patients who had died of contagious or infectious diseases, 
 within 24 hours thereafter, with a statement of the specific name and type of 
 disease. The keepers of all hotels and boarding-houses, the agents and owners 
 of all tenement houses or private residences or dwellings, and the commis¬ 
 sioners, managers, principals, or other proper person or head officer of every pub¬ 
 lic or private institution in the city were required to report in writing, within 24 
 hours, to the commissioner of health, the names and ages of each and every 
 one of the inmates of all such houses suffering from any of the above-mentioned 
 diseases. The same rules applied to the masters and agents of vessels not within 
 
58 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 quarantine, or within quarantine limits but being within one-fourth of a mile 
 of any dock, wharf, or building of the city. Persons were forbidden to bring 
 to any dock, wharf, or building, or within 1,000 feet thereof, or to have on 
 storage in the city any skins, fish, rags, bones, hides, or similar articles or 
 materials brought from any infected place, except with the written permission 
 of the commissioner of health. The sale of articles of any kind that had been 
 exposed to any contagious disease before they had been adequately cleansed 
 or disinfected and without a written permit from the commissioner of health 
 was forbidden. Without permission from the commissioner of health, no person 
 sick with any contagious disease could be carried from one building to another 
 or from any vessel to the shore. The needless exposure of any individual to 
 those sick with any contagious disease was forbidden. Bodies of all persons dead 
 of any contagious disease were to be buried within 24 hours after death unless 
 this time was extended by the commissioner of health, and no such bodies 
 could be exposed to the peril or prejudice of the life or health of any person. 
 The commissioner of health was instructed to give public notice of infected 
 places by displaying a yellow flag on the premises where infectious diseases 
 existed, and he was given the power to remove any baggage, clothing, bedding, 
 or goods of any character suspected of being infected with any contagious or 
 infectious disease. In every case where there had been small-pox, diphtheria, 
 scarlet fever, or other contagious diseases, and the sick person had either died 
 or been removed from the premises where the disease existed and the occupants 
 had vacated the property without causing a thorough and complete fumigation 
 and disinfection of said property, the owners were required to do this before 
 any person or persons could visit the property with the purpose of becoming 
 tenants or owners. 
 
 The use of hackney coaches, buggies, cabs, and gigs for public hire for the 
 removal of persons suffering from small-pox, scarlet fever, diphtheria, or other 
 contagious diseases to or from any point in the City of Baltimore, or of any body 
 dead of such diseases, was forbidden under penalty of having it or them taken 
 by the commissioner of health, disinfected, fumigated, and quarantined for 
 30 days, unless it or they were used for that purpose only. 
 
 The list of diseases reportable by physicians was expanded by the ordinance of 
 May 20, 1890, to include membranous croup, measles, mumps, and whooping- 
 cough. It is strange that both typhus and typhoid fevers were omitted from 
 these lists. The former was surely known at that time to be a “ contagious and 
 infectious ” disease, and had been so held by the health department since its 
 establishment, as is seen from the reports of the department. 
 
 On May 29, 1895, typhoid fever was by ordinance added to the list of reporta¬ 
 ble diseases. The importance of reporting cases of pulmonary tuberculosis was 
 recognized by the ordinance of May 12, 1896. The commissioner of health was 
 directed to register the name and address, sex, and age of every person suffering 
 from pulmonary tuberculosis, so far as such information could be obtained, 
 and all physicians were requested to forward such information on cards ordi¬ 
 narily employed for the report of cases of contagious diseases, this information 
 to be solely for the use of the commissioner of health. In no case was the com¬ 
 missioner of health to assume any sanitary surveillance of such patients unless 
 the patients resided in tenement houses, boarding-houses, or hotels, or unless 
 the attending physician requested that an inspection of the premises be made. 
 
DEVELOPMENT OF HEALTH DEPARTMENT AND HEALTH LAWS, ETC. 59 
 
 In no case, unless the patient resided in a tenement house, boarding-house, or 
 hotel, could any inspection be made if the physician requested that no visits 
 be made by inspectors and was willing himself to deliver the circulars of infor¬ 
 mation designed to prevent the communication of the disease to others. This 
 lame ordinance was passed after vigorous effort on the part of the officials 
 of the health department and a few prominent physicians and laymen and 
 against considerable opposition. It gave the health department but little power 
 of control over the individuals affected with this disease and bore all the ear¬ 
 
 marks of having been written by those opposed to such control. 
 
 An ordinance directed against indiscriminate expectoration was passed on 
 February 21, 1905. It contained the following provisions: It shall not be 
 lawful for any person to expectorate or spit in or upon any paved sidewalk or 
 brick path of any public street, avenue, or public square in the city of Balti¬ 
 more, or in or upon any park or any building under the control of the mayor 
 and city council of Baltimore City, or upon the floor, platform, or steps of any 
 street-railway car, or other vehicle carrying passengers for hire, or upon the 
 floor of any depot or station, or upon the station platform or stairs of any ele¬ 
 vated railroad or other common carrier, or upon the floor or steps of any 
 theater, store, factory, or any building which is used in common by the public, 
 or upon the floor of any hall or office, in any hotel or lodging-house which is 
 used in common by the guests thereof. Corporations or persons owning or man¬ 
 aging any of the above-mentioned public vehicles or buildings, etc., are required 
 to keep posted permanently and conspicuously in such places notices prohibit¬ 
 ing spitting on floors, etc. Sufficient and proper receptacles for expectoration 
 must be provided which shall be cleansed and disinfected once in every 24 hours. 
 
 All other diseases now reportable have been made so either by act of the State 
 Legislature, or by resolution of the State board of health, which acts or reso¬ 
 lutions apply to the whole State. In 1920, the list of diseases notifiable in 
 Maryland included: 
 
 Anthrax (malignant pustule). 
 Bubonic plague. 
 
 Cerebro-spinal meningitis (epidemic). 
 Chancroid. 
 
 Chicken-pox. 
 
 Cholera (Asiatic). 
 
 Dengue (breakbone fever). 
 Diphtheria (membranous croup). 
 Dysentery (acute). 
 
 Erysipelas. 
 
 German measles. 
 
 Glanders (farcy). 
 
 Gonorrhoea. 
 
 Influenza (grippe). 
 
 Leprosy. 
 
 Malaria. 
 
 Measles. 
 
 Mumps. 
 
 Ophthalmia neonatorum. 
 
 Pellagra. 
 
 Pneumonia (lobar). 
 
 Pneumonia (broncho). 
 
 Poliomyelitis (infantile paralysis). 
 Rabies (hydrophobia). 
 
 Relapsing fever. 
 
 Scarlet fever (scarlatina, scarlet rash). 
 Septic sore throat. 
 
 Small-pox (variola, varioloid). 
 Syphilis. 
 
 Trachoma. 
 
 Tuberculosis (report on special card). 
 Typhoid fever. 
 
 Typhus fever. 
 
 Venereal diseases. 
 
 Whooping-cough. 
 
 Yellow fever. 
 
 QUARANTINE OF THE PORT. 
 
 A resolution of the mayor and city council of Baltimore, approved March 19, 
 1801, instructed the mayor to apply to the United States Government for 
 purchasing suitable warehouses with the requisite wharves and inclosures at 
 5 
 
60 
 
 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 some convenient place near the port of Baltimore where goods and merchandise 
 could be unladen in accordance with the city ordinances. 
 
 An ordinance of the same date amplified the quarantine provisions of the 
 original ordinance, the most important section stating: 
 
 “ And be it enacted and ordained, that all vessels coming from either of the Indies, 
 the coasts of Africa and South America, or any port or place in the Mediterranean, or 
 the seas or waters connected with the same to the eastward of the Straits of Gibraltar, 
 including all and every other port or place on the western side of Spain as far as Cape 
 St. Vincent, from the first of May to the first of November, shall perform a quaran¬ 
 tine of 3 days, during which time the health officer shall be compelled to pay them a 
 visit daily, wind and weather permitting, and if at the last visit a further detention be 
 necessary, he shall oblige the same to continue their quarantine, not exceeding 10 
 days; and in all such cases the health officer shall give a certificate to the master or 
 captain of the vessel, signed with his name, expressing the number of days the said 
 vessel is to ride quarantine; and the health officer is hereby enjoined to pay another 
 visit to the said vessel before the expiration of her quarantine, and if necessary to 
 continue the same any number of days not exceeding 5 days for each quarantine.” 
 
 Vessels arriving from the West India Islands, or other parts, in the months 
 from June to October, inclusive, and loaded with coffee liable to damage or pu¬ 
 trefaction, were not allowed to come into port, but their cargoes were landed and 
 aired or discharged into other vessels while remaining in the river, or in the 
 “ bite ” within or near Love’s Point, except when special permission was granted 
 by the mayor with the approbation of the commissioners of health. All the ves¬ 
 sels arriving from the ports or places enumerated in that section of this ordi¬ 
 nance previously referred to were to discharge their cargoes and ballast at the 
 quarantine-ground in houses for this purpose, under the inspection of a health 
 officer and representatives of the custom house, before they could be brought to 
 the city. The ship and the wearing apparel of every person on board were to be 
 well cleansed and ventilated before persons could obtain a permit from the health 
 officer to come to the city. Persons sick or in a disordered state on vessels were 
 to be sent to the hospital, or such lazaretto as would be provided for them, 
 and the board of health was empowered to obtain the necessary provisions and 
 other articles for the accommodation of the sick. No disordered person so 
 detained could leave the lazaretto or hospital without the permission of the 
 attending physician in writing. Vessels required to perform quarantine were 
 permitted to send their letter-bags to the post-office by the health officer in such 
 manner as the board of health directed. 
 
 The quarantine officer and his assistant were required by the ordinance of 
 March 18,1807, to be at Fort McHenry every day between 8 a. m. and 6 p. m., if 
 not otherwise engaged in the discharge of their duties. The quarantine officer 
 was required to enter into a book kept for the purpose all marine intelligence 
 obtained from the masters of vessels arriving at the quarantine-ground. This 
 book was to be kept open in his office for the examination of every person. 
 The health officer was required to visit all vessels immediately upon their 
 arrival, wind and weather permitting, coming from beyond the seas or from 
 places where contagious disease was suspected to exist, from the last of April 
 to the first of November of each year. 
 
 The ordinance of March 17, 1808, repealed such part of the recently passed 
 health ordinance as required the quarantine of vessels and appointment of 
 a health officer (quarantine physician). 
 
DEVELOPMENT OF HEALTH DEPARTMENT AND HEALTH LAWS, ETC. 61 
 
 According to the ordinance of May 5, 1809, permission was hereafter to be 
 obtained from the mayor to bring into port vessels loaded with articles liable to 
 damage. 
 
 The new health ordinance of February 29, 1820, which was passed after the 
 great yellow-fever epidemic and was drawn up under the influence of the sug¬ 
 gestions of the committee of the Medical and Chirurgical Faculty, contained 
 no reference to quarantine. 
 
 The ordinance of March 14, 1821, provided that all vessels with passengers 
 from sea voyages should be subject to the orders of the Board of Health which 
 could authorize the landing of persons in perfect health. 
 
 According to the ordinance of March 27, 1821, no ballasts could be landed 
 from ships between May and October, until permission was obtained from the 
 Board of Health. 
 
 Quarantine was reestablished by the ordinance of March 11, 1823, which pro¬ 
 vided that all vessels arriving from foreign ports or places and all coasting- 
 vessels should come to the quarantine-grounds until boarded by the health of¬ 
 ficer, who was required to retain such vessels until he was satisfied that no 
 vegetable substances in a putrid state or other damaged articles were on board. 
 If the conditions of the vessels or cargoes were, in his opinion, such as to en¬ 
 danger the health of the city, he was required to order such airings and cleans¬ 
 ings at the lazaretto as he might deem necessary. All vessels found in a safe 
 and clean condition and all coasting-vessels from the eastward of Cape Charles 
 and the vessels from the southward laden with naval stores and lumber only 
 were permitted at the discretion of the health officer to pass up into any part 
 of the basin without restriction, but not within 200 yards of any wharf on 
 the north side of the basin. Here such vessels came under the jurisdiction of the 
 commissioner of health, without whose permission, given after an examination 
 of their cargoes, they could not unload. The commissioner might cause such 
 vessels to be cleaned before coming to any of the wharves or docks of the city. 
 Commissioners of health were not allowed to permit the unloading of any cargo 
 arriving from the West Indies, Hew Orleans, Florida, South Carolina, Georgia, 
 the Gulf of Mexico, or South America, at any wharf on the north side of the 
 basin or harbor, or on the south side to the eastward of Harbougbis Wharf. 
 These quarantine measures were applicable from the first of May to the first of 
 November. One section of this ordinance provided that every public or private 
 armed vessel sailing under commission and every vessel having more than 15 
 passengers, arriving from sea, were to land their ballasts, empty their water- 
 casks, and cleanse them while at the quarantine or at the lazaretto, so that 
 timber boards could be taken up and the timbers well cleansed and approved by 
 the aforesaid officer before such vessel would be permitted to come to any wharf 
 or dock within the limits of the city. Vessels whose ballasts consisted of salt 
 were exempted from these provisions. 
 
 By an ordinance of March 24, 1826, all the better features of the old quaran¬ 
 tine laws were reenacted and the whole matter of quarantine was put in charge 
 of the health officer (quarantine physician), under the commissioners of health, 
 who were to decide whether and to what degree quarantine was to be imposed 
 on coastwise vessels and vessels from foreign ports. All such vessels were re¬ 
 quired to anchor at or near Love Point for inspection by the health officer, who. 
 
62 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 after examination of their crews and of the condition of the cargoes and ves¬ 
 sels, passed them if he considered them safe. Otherwise, the vessels went to 
 the lazaretto for cleaning, where the cargoes and passengers were discharged. 
 Here, any sick were to be separated from the well. Private armed vessels or 
 vessels having more than 15 passengers were required to submit to the conditions 
 of the previous ordinance applying to them. The lazaretto was lost by fire in 
 1836. 
 
 According to the ordinance of May 27, 1847, the health officer was to 
 inspect all passengers and passenger ships from foreign countries, and whenever, 
 in his opinion, the health of the city might be endangered either from the 
 absolute presence of disease or from an unclean condition of the ship or pas¬ 
 sengers, he was empowered to require such ship to come to anchor at the quar¬ 
 antine-ground and undergo the usual procedures. It would appear from this 
 ordinance that the quarantine at this time extended only to passenger vessels. 
 
 The ordinance of June 18, 1847, made it unlawful to carry from any ship 
 through any street, lane, or alley of the city any person or persons infected 
 with any infectious disease. Ho material change occurred in the ordinances 
 relating to quarantine until June 20, 1874, when it was provided in the revised 
 ordinances that vessels arriving from points north of Cape Henry, free from 
 epidemical or contagious diseases, and with cargoes from said ports, should 
 not be subject to the usual quarantine regulations, unless in the judgment of 
 the board of health compliance with these stipulations would be necessary to 
 protect the health of the city. 
 
 From this date until the quarantine regulations and practices of the country 
 were made uniform and under the general direction and with the cooperation 
 of the United States Marine Hospital Service and its successor, the United 
 States Public Health Service, no material changes were made. 
 
 REGISTRATION OF BIRTHS AND DEATHS; DEATH CERTIFICATES; PER¬ 
 MITS FOR BURIAL AND TRANSPORTATION OF DEAD BODIES; 
 
 REGISTRATION OF PHYSICIANS, MIDWIVES AND 
 
 UNDERTAKERS. 
 
 By ordinance passed October 6, 1874, and effective January 1, 1875, it was 
 required that deaths occurring within the city should be reported to the com¬ 
 missioner of health within 48 hours by the physician in attendance, or in suit¬ 
 able cases by coroners, and that persons practicing midwifery should similarly 
 report each month all births attended by them. In the case of births unattended 
 by a physician or midwife, the duty of reporting, except in the case of births 
 and deaths of illegitimate children, devolved on the father or mother of the 
 child. On death certificates it was required to record the full name of the de¬ 
 ceased (and if a minor the name of his father and mother), his color, sex, 
 age, occupation, social state, birthplace, date and cause of death, the ward, 
 street, and number of the residence, and the dates of burial, certification, and 
 registration. These certificates conveyed directly to the health department the 
 information concerning deaths which had hitherto been furnished it through 
 the sextons of cemeteries. This new law also placed interments and disinter¬ 
 ments directly under the control of the commissioner of health. 
 
 Birth certificates were required to give the full name and the sex and color 
 of the child, the full names of the father and mother, the day, month, and 
 
DEVELOPMENT OF HEALTH DEPARTMENT AND HEALTH LAWS, ETC. 63 
 
 year of birth, the street and number of house where born, the name and resi¬ 
 dence of the physician, midwife, or other person signing the certificate, and 
 the date of certification and registration. 
 
 To further the carrying out of these provisions, physicians, midwives, un¬ 
 dertakers, and sextons of cemeteries were obliged to register their names and 
 residences at the health office. Uniform certificate blanks for deaths and births 
 were supplied by the commissioner of health. They were modified but little un¬ 
 til the introduction of the standard certificates of the Bureau of the Census. 
 The original law was amplified, but in relatively minor ways, by amendment in 
 1884, 1898, and 1904. 
 
 Ordinance 15 , Approved April 11 , 1797 . 
 
 An ordinance to prevent and remove nuisances in the city of Baltimore, 
 and within the precincts thereof, and to provide an uniform mode for clean¬ 
 ing the streets, lanes, and alleys within the said city. 
 
 “ Be it enacted and ordained by the Mayor and City Council of Baltimore, That the 
 inhabitants and occupiers of houses and lots, and sextons, porters or other keepers of 
 churches, meeting-houses or other public buildings, or burying grounds, fronting the 
 paved streets, lanes or alleys within the said city, shall rake and sweep into the cart¬ 
 way, the dirt, soil, or filth to be found on the brick pavements, foot-ways and gutters 
 before their respective houses, lots, dwellings or public buildings, or cause the same to 
 be done once in every week, that is to say on every Friday, by ten o’clock in the fore¬ 
 noon (when the snow or ice on the same does not prevent) that it may be removed 
 as is hereinafter provided, under the penalty of any sum not exceeding one dollar for 
 every neglect or refusal, for the use of the city. 
 
 “ And be it enacted and ordained, That no person or persons whomsoever shall cast 
 or lay, or cause to be cast or laid, any oyster shells, shavings, ashes, dirt or stable 
 manure on any of the streets, lanes or alleys of the said city (unless the same be 
 placed or laid in front of his, her or their lot, and removed within two hours) under 
 the penalty of two dollars for every such offence, for the use of the city. 
 
 “ And be it enacted and ordained, That no person shall cast, place or throw down any 
 rubbish, dirt or materials for building in any public street, lane or alley of the said city, 
 save only in such parts and places as shall be appointed and agreed on by the persons 
 duly authorized therefor under the penalty of one dollar, for the use of the city, for 
 every two hours after notice to remove the same. Provided, that nothing in this or¬ 
 dinance shall be construed to extend to any person or persons employed in building or 
 repairing any house, houses or tenements, so far as shall relate to materials necessarily 
 used in making such building or repairs; but the said person or persons engaged as 
 aforesaid, may use and occupy one-third part in width of any street, lane or alley, clear 
 of the foot-way in front of any lot on which such building is erecting, or repair making, 
 until the same shall be covered in, and twenty days thereafter, and no longer, nor to 
 any person or persons engaged in plastering his, her or their house or houses, but such 
 person or persons shall have a right to use and occupy with plastering, mortar or other 
 materials necessary therefor, one third of any street, lane or alley in front of his, her or 
 their lot or lots, sixty days, and no longer, without the permission of the City Com¬ 
 missioners, under the penalty of one dollar for every two hours, for the use of the 
 city; nor shall the provisions of this ordinance extend to any person or persons dropping 
 fire wood or stone coal at his, her or their door, provided the foot-way be not incom¬ 
 moded therewith, or by the sawing or cutting of said wood; and the said fire wood or 
 stone coal be removed within two days after the same shall be dropped as aforesaid, 
 under the penalty of one dollar for every day thereafter, for the use of the city. 
 
 “ And be it enacted and ordained, That if any person or persons whomsoever, shall 
 set or place any goods, wares or merchandise, by way of exposing them to sale, on or 
 over the brick or stone pavement, in any public street, lane, or alley in this city, to 
 project more than twelve inches from the wall of his, her or their house or store, every 
 such person shall pay a fine of one dollar, for the use of the city: Provided, that this 
 
64 
 
 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 clause shall not extend to, or interfere with any regulation in the ordinance concern¬ 
 ing the markets, nor extend to goods sold at public auction. 
 
 “ And be it enacted and ordained, that any person who shall place or pile any empty 
 boxes, barrels, hogsheads or other conveniency, capable of containing goods or mer¬ 
 chandise, or that may have contained goods or merchandise, in any part of the streets, 
 lanes or alleys of this city (except as is before excepted) and shall not remove them 
 from the same within four hours after they shall have so been placed or piled there, 
 every such person shall pay a fine of one dollar for every four hours the same shall 
 thereafter be suffered so to remain, for the use of the city. 
 
 “ And be it enacted and ordained, That if any tanner, currier, distiller, brewer, soap 
 boiler, tallow chandler, hatter, dyer, glue boiler, or any other person within the said 
 city, shall discharge any foul or nauseous liquor, or offal, from any still-house, workshop, 
 or yard, so that such liquor or offal shall pass into or along any of the streets, lanes or 
 alleys of the said city; or if any soap boiler or tallow chandler shall keep, collect or 
 use, or cause to be kept, collected or used in any part of the said city, any stale, putrid 
 or stinking fat, grease or other offensive matter; or if any butcher shall keep at or near 
 his slaughter house, any garbage or filth whatsoever, so as to annoy any neighbor, or 
 any person whomsoever, he, she or they shall forfeit and pay, for every such offence, 
 the sum of five dollars, and shall also forfeit and pay the like sum for every day the 
 same shall be suffered so to remain, for the use of the city. 
 
 “ And be it enacted and ordained, That if any person or persons having a hog or 
 hogs within their enclosures in sties, shall keep the same in such manner that the stench 
 and filth thereof shall become offensive to, and annoy any neighbor or person whom¬ 
 soever, the person or persons so keeping his or their hog or hogs as aforesaid, shall 
 forfeit and pay for every such offence, one dollar, and shall also forfeit and pay the 
 like sum for every day the same shall be suffered so to continue, for the use of the 
 city. 
 
 “ And be it enacted and ordained, That no person or persons whomsoever, shall cast, 
 carry, draw out or suffer to lay any dead horse or other dead carcase, or any excrement 
 or filth from vaults, privies or necessary houses in any part of the said city, precincts 
 or harbor of Baltimore; any person or persons offending herein, shall forfeit and pay 
 five dollars for every such offence, together with the expense of removing the same, 
 for the use of the city. 
 
 “ And be it enacted and ordained, That the city commissioners shall on the Friday or 
 Saturday of every week, have the dirt and filth found on any of the paved streets, 
 lanes or alleys of the said city, removed therefrom, and deposited in such place or 
 places as may for that purpose be by them provided; which dirt or filth shall after¬ 
 wards be disposed of in such manner and upon such terms as the said Commissioners 
 shall from time to time direct and appoint: Provided, nevertheless, that the said com¬ 
 missioners may permit any person or persons to collect and carry away the said dirt and 
 filth, or may contract with any person or persons for the removal of the same, or any 
 part thereof, so that the same be removed on the Friday or Saturday of each week as 
 aforesaid, under the penalty of one dollar, for the use of the city, for each and every 
 square of the said city not cleaned as aforesaid. 
 
 “ And be it enacted and ordained, That every person or persons possessing a lot or 
 lots, w r hich from their low and sunken situations are liable to retain tide or rain water, 
 or on which cellars or foundations for buildings may be dug, and no tenement erected 
 over the same, shall, during the months of June, July, August, September, and October, 
 preserve and keep the said lots, cellars and foundations dry and free from stagnant or 
 putrid waters and other filth; any person or persons offending herein, shall forfeit and 
 pay five dollars, for the use of the city, for every week he, she or they shall suffer such 
 stagnant or putrid water or other filth to remain thereon. And if the said owner or 
 owners shall, notwithstanding the above provision, neglect to remove such stagnant or 
 putrid water or other filth, the city commissioners may employ such person or persons 
 as they may think proper, and upon such terms as to them may seem reasonable and 
 just, to remove from the said lot or lots, cellars or foundations, the said filth or stag¬ 
 nant or putrid water, which said expense shall be considered as a further fine for not 
 complying with the provisions of this clause, and shall be collected accordingly. 
 
 “ And be it enacted and ordained. That every person or persons possessing a tenement 
 or tenements, warehouse or warehouses on any part or parts of the made ground of 
 
DEVELOPMENT OF HEALTH DEPARTMENT AND HEALTH LAWS, ETC. G5 
 
 said city, under which a cellar is or may be dug, or vacant space left, shall, during the 
 months of June, July, August, September, and October, keep the same dry and clear 
 of stagnant water, mud or filth, and shall at least once in every week, empty and 
 clear out any stagnant water, mud, or filth from the said cellar or empty space left as 
 aforesaid; any person or persons offending herein, shall forfeit and pay for every of¬ 
 fence five dollars, for the use of the city. 
 
 “ And be it enacted and ordained, That the owner or owners of any cart, wagon, or 
 other carriage, that shall or may be employed in removing or carrying off any of the 
 paved streets, lanes, or alleys of the city, any sand, loam, gravel, earth, dirt, manure, 
 stone, bricks, or coal, shall have and keep the same in such tight and secure condition 
 so that such sand, loam, gravel, earth, dirt, manure, stone, bricks or coal, be not scat¬ 
 tered or suffered to fall on any of the streets, lanes or alleys aforesaid, under the penalty 
 of seventy-five cents, for the use of the city. 
 
 “ And be it enacted and ordained, that if any person or persons shall willfuly and 
 needlessly fire, shoot, or discharge any gun, pistol, or other fire-arms, or make any bon¬ 
 fire, or burn any combustible matter in any of the streets, lanes or alleys of the said 
 City, every such person for every such offense shall forfeit and pay one dollar for the 
 use of the City. 
 
 “ And whereas, great injury may arise to the citizens of Baltimore from the going 
 at large of hogs, goats, and geese therein: 
 
 “ Be it enacted and ordained, That the city commissioners shall employ one or more 
 persons to seize and take all hogs, goats, and geese found at large within the said City, 
 and the same to sell and dispose of at public sale, for the use of the City. 
 
 “ And be it enacted and ordained, That this ordinance shall commence and be in force 
 from and after the first of May ensuing, and continue until the first day of January 
 next, and until the end of the next session of the corporation that shall happen there¬ 
 after.” 
 
 The foregoing ordinance was modified and expanded from time to time 
 by later ordinances. 
 
 The character of the modifications and the dates they were made can be 
 most clearly presented under separate activities, all of which, however, fall 
 under two general headings, sanitation on public and on private domains. 
 
 SANITATION ON PUBLIC DOMAINS. 
 
 Street cleaning .—In 1798, occupiers or owners of houses and lots on paved 
 streets, lanes and alleys were required to clean the gutters in front of them 
 once daily, Sundays excepted, before 10 a. m. The same year the city began 
 to sell street refuse, a practice which was continued for many years. The office 
 of superintendent of street cleaning was created at this time, and in one form 
 or another this office has been continued. Street cleaning, previously under the 
 city commissioners, was transferred to the board of health from 1845 until 
 1881, when a separate department was established under an independent com¬ 
 missioner. Except for a few years after 1849, when the cleaning of streets was 
 let out to contractors, this work was done by employees of the city. 
 
 COLLECTION AND DISPOSAL OF GARBAGE. 
 
 In 1821 the superintendent of streets was required to collect garbage on 
 Tuesdays, Thursdays, and Saturdays from May 1 to November 1, and in 1850 
 watertight and covered carts were provided for garbage and ash removal, and 
 the removal of offal and garbage from the markets was undertaken. In 1S77 
 it was provided by law that all garbage and other like refuse, which heretofore 
 had been deposited on dumps within or near the city limits, should be trans- 
 
66 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 ported by rail or water at least 6 miles from the city limits. From 1904 until 
 1919 garbage so removed was rendered under contract at a point on the bay 
 well beyond the city. 
 
 NIGHT-SOIL DISPOSAL. 
 
 In 1880, the administrative authorities were granted power to enter into 
 contract to have the night-soil, which heretofore had been deposited on dumps 
 with the garbage, transported by barges to proper places beyond the city. As 
 the laws relating to paving, sewers, and water supplies have to do much more 
 with the inauguration than with the regulation of these services, they are 
 omitted here. 
 
 SANITATION ON PRIVATE DOMAINS. 
 
 The health officer or the commissioners of health were empowered by the 
 ordinance of February 28, 1798, to order any damaged hides, coffee, or other 
 damaged goods found within the city to be removed therefrom to a distance not 
 exceeding 3 miles. The ordinance of March 20, 1801, gave authority to the 
 commissioner of health to enter all lots, grounds, and buildings on which 
 nuisances of any description might exist, and refusal or neglect to abate nui¬ 
 sances on the order of a commissioner of health was made punishable by a fine 
 of $20. This power was amplified by the ordinance of March 22, 1803, to in¬ 
 clude cellars and docks. According to the ordinance of February 10, 1820, each 
 commissioner of health was required to inspect, at least once every two weeks 
 between the first day of March and the first day of November, all cellars, yards, 
 lumber-yards, lots, and docks (in addition to streets, lanes, and alleys) within 
 his district and to remove or cause to be removed all nuisances. 
 
 PRIVIES, CESSPOOLS, AND NIGHT-SOIL. 
 
 The ordinance of February 28, 1798, empowered the commissioners of health 
 to appoint, license, or remove all night-soil men. 
 
 By the ordinance of March 18, 1811, it was made unlawful to erect a privy 
 or other building over a wharf or stone wall on Jones Falls, within the limits 
 of the city, which would discharge into the falls except by means of a sewer 
 emptying below the high-water mark. 
 
 According to the ordinance of March 18, 1817, no well or hole could be 
 sunk for the purpose of erecting a privy over it or of depositing any odure or 
 other filth therein or of depositing any odure in or upon the surface of the 
 earth (except in privies already erected) in that part of the city bounded on 
 the north by Franklin Street, on the west by North Charles Street, on the south 
 by New Church Street, and on the east by North Calvert Street. 
 
 The ordinance of March 9, 1820, required that all dead animals, including 
 fish, and all excrement or filth from vaults and privies, should be so covered 
 with earth on removal as to prevent any noxious effluvia arising from them. 
 It was also unlawful to discharge into any street, lane, or alley of the city any 
 foul or nauseous liquors, or any other offensive matter. 
 
 It was provided in the ordinance of March 27, 1820, that the vault or well 
 of every privy which should be erected within certain limits (apparently about 
 a block) on each side of the Eastern Spring and the Western Spring should be 
 
DEVELOPMENT OF HEALTH DEPARTMENT AND HEALTH LAWS, ETC. 67 
 
 built and floored with sound and well-burned brick, at least 1 foot thick at the 
 bottom and not less than 9 inches thick for the walls, and set in with a cement 
 impervious to water. These vaults were not to exceed 6 feet in depth and were 
 to be well puddled with clay rammed compactly at the bottom and on all sides 
 of every such privy at least 1 foot thick. It was further provided that every 
 privy heretofore or hereafter to be erected, all being within the aforesaid limits, 
 be cleaned out at least once every year, and oftener if required, by the com¬ 
 missioners of health. If the commissioners of health found any privy heretofore 
 erected within the limits described likely to injure or corrupt the waters of 
 the springs, they were to order the owner to clean it out and rebuild it. 
 
 Through the ordinance passed in November 1821, it was ordered that all 
 privies kept for private use on docks, wharves, or made ground be made water¬ 
 tight and sprinkled weekly with lime from the first of May until the first of 
 November. This ordinance further provided that a public privy be constructed 
 on each of the public wharves where it was deemed expedient and in the vicinity 
 of the several market-houses, and that all other privies hereafter to be con¬ 
 structed within the limits of direct taxation were to be made water-tight. No 
 person was permitted to drain a privy to cover its contents, but the contents 
 were to be cleaned out and removed without the limits of the city. 
 
 It became the duty of the board of health by the passage of the ordinance of 
 October 26, 1872, to cause inspections of privies to be made between the first 
 and tenth of June by the police, who were required to report those in a state 
 of nuisance which were found full or likely to become full before the first of 
 October. It was further provided that the emptying and removal of the con¬ 
 tents of privies should be done between the first of October and the first of 
 June. 
 
 The ordinance of November 1, 1873, empowered the board of health to permit 
 any person to clean sinks and privy vaults during the day time, provided the 
 receptacle was air-tight and the work could be done without annoyance to 
 citizens. 
 
 The board of health was empowered by the ordinance of June 17, 1886, to 
 clean, privies and to abate other nuisances at the expense of the owners, agents, 
 or occupiers, when they had neglected or refused to do so. There was to be 
 no cleaning of privies between the first of June and the first of October unless 
 it was deemed necessary for the health and comfort of the neighborhood. 
 
 On October 23, 1891, it was ordained that every well used as a cesspool 
 should be covered with stone not less than 4 inches thick or with iron not less 
 than 1 inch thick, should be at least 6 feet deep, and walled up with brick and 
 stone, and should be well and satisfactorily built. When a well was to be used 
 as a privy, the floor was to be covered its full length and width with the material 
 and thickness as above stated. In all cases such wells and privies were to be 
 water-tight. 
 
 The ordinance of February 26, 1906, made it unlawful hereafter to construct 
 any privy well to be used in connection with more than one house. 
 
 MEASURES AGAINST STANDING WATER AND DECAYING VEGETABLE 
 MATERIAL ON LOW GROUNDS, WHARVES, AND DOCKS. 
 
 It was made unlawful by the ordinance approved March 6, 1820, to fill in the 
 wharves and low grounds, in any part of the city, with any kind of wood, 
 
68 
 
 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 shavings, or vegetable matter. It was further provided that no spars, arks, logs, 
 or timber, with any bark or sap on them, other than square timber, should re¬ 
 main in the water of the harbor or in any situation within 200 yards of any 
 dwelling or wharf where a common tide could reach them, without the written 
 permission of the board of health. This provision extended from the first of 
 June until the first of November. The throwing of any kind of animal, 
 fruit, or vegetable matter into the basin or dock or into Jones Falls was for¬ 
 bidden during the same period of time. 
 
 The ordinance of March 27, 1821, required that owners of all lumber, ship, 
 cooper, and wood yards and saw mills on low or made ground should, at the 
 discretion of the board of health, cover the ground with a sufficiency of fresh 
 earth and lime and from time to time burn their vegetable offals. It was re¬ 
 quired that all wood-yards for the deposit or sale of firewood be raised above 
 standing water and the wood piled in such a way as to permit the free circula¬ 
 tion of air. The board of health was authorized to compel the owner or owners 
 of any vacant lots to keep them clear of nuisances and to grade them so as to 
 prevent any water from remaining upon them. 
 
 By this same ordinance the board of health was required to order the 
 cleansing of the heads of docks, sewers, and tunnels, and the deposits of sewers. 
 All wharves where wood was landed were to be scraped as often as the board 
 of health might require in order to prevent the offals of the wood from falling 
 into the docks or basin. This offal, with the deposits from the sewers and the 
 heads of docks, was to be disposed of as manure. This ordinance prohibited 
 the floating of square timber in the water of the harbor. 
 
 It was required by the ordinance of November 1821, that not less than 3 
 feet of water be obtained at the lowest common tide at the docks and wharves 
 of the city between the first of June and the first of October. The board of 
 health was authorized to prohibit all offal and deposits of privies, factories, 
 distilleries, butchers’ and other shops, the jail, penitentiary, and other foul 
 premises from being dumped into any of the streams of water or public sewers 
 within the city or in Jones Falls, and all private sewers, carrying other than 
 clean water, from entering these falls. The public sewers were to be cleaned 
 weekly from the first of April until the first of October. 
 
 The ordinance of March 8, 1822, repealed that part of the last ordinance 
 which required that the board of health be authorized to prohibit all offal from 
 being deposited in the waters of Jones Falls. 
 
 The commissioners of health were empowered by an ordinance approved 
 March 11, 1823, to drain instead of fill up low grounds, when in their opinion 
 draining would answer the intended purpose and where the ground to be 
 drained was not bounded by any street, lane, or alley. 
 
 On June 22, 1915, the following ordinance for the prevention of the breeding 
 of mosquitoes was approved: 
 
 “ 1. It shall be unlawful to have, cause, maintain, or permit within the municipality 
 of Baltimore, any collection of standing or flowing water in which mosquitoes breed, 
 or are likely to breed, unless such collection of water is treated so as to effectually 
 prevent such breeding. 
 
 “ 2. The collections of water referred to in section 1 of this ordinance shall be held to 
 be those contained in ditches, gutters, rain gutters or roof gutters, ponds, pools, ex¬ 
 cavations, holes, depressions, open cesspools, privy vaults, fountains, cisterns, tanks, 
 
DEVELOPMENT OF HEALTH DEPARTMENT AND HEALTH LAWS, ETC. 69 
 
 shallow wells, barrels, troughs (except horse troughs in frequent use), urns, cans, boxes, 
 bottles, tubs, buckets, or other similar containers. 
 
 “ 3. The methods of treatment of the collections of water specified in section 2 so as 
 to prevent breeding of mosquitoes shall be any one or more of the following: 
 
 “ (a) Screening with wire netting of at least 16 meshes to the inch each way, or any 
 other material which will prevent the ingress or egress of mosquitoes. 
 
 “ (6) Complete emptying every 7 days, or at shorter periods, of unscreened containers. 
 
 “ (c) Using a larvicide approved and applied under the direction of Dr. Henry R. 
 Carter, assistant surgeon general of the United States Public Health Service, or any one 
 deputized by him for that purpose. 
 
 “ ( d ) Covering completely once every 7 days the surface of the water with kerosene, 
 petroleum, or paraffine oil in sufficient quantities to remain covered at least 12 hours 
 each time. 
 
 “ ( e ) Cleaning and keeping sufficiently free of vegetable growth and other obstruc¬ 
 tions, and stocking with mosquito-destroying fish; absence of half-grown or large mos¬ 
 quito larva to be evidence of compliance with this measure. 
 
 “ (/) Filling or draining to the satisfaction of the commissioner of street cleaning ol 
 Baltimore City, or any one deputized by him for that purpose. 
 
 “ ( g ) The removal of tin cans, tin boxes, broken or empty bottles, and similar articles 
 likely to hold water, at least once every 7 days. If not removed they must be so com¬ 
 pletely destroyed as not to be able to hold water. 
 
 “ 4. Any person who shall violate any provision of this ordinance shall on each 
 conviction be subject to a penalty of not less than one nor more than ten dollars, to 
 be collected as other penalties imposed by ordinance, and the payment of any costs 
 incurred under paragraph 5 hereof.” 
 
 CELLARS. 
 
 The board of health was required by the ordinance of March 27, 1821, to 
 see that all cellars on low or made ground were filled up or otherwise im¬ 
 proved at the expense of their owners. 
 
 In November 1821, an ordinance was passed requiring that all cellars and 
 other confined surfaces on low or made ground “ and where yellow fever is 
 liable to prevail ” be filled so as to preserve them as dry as possible; that they 
 be kept clean and well aired and sprinkled from time to time with fresh earth 
 and lime; and that all cellars on made ground be ventilated by properly con¬ 
 structed flues and by leaving a space not filled in, or by raising the floor, or 
 both, so as to admit cleaning them. 
 
 It was provided by the ordinance of March 11, 1823, that all cellars and 
 vacancies under stores or warehouses on made ground should, when it was 
 deemed necessary by the board of health, be filled by sound materials and 
 paved with hard bricks or stone; that the lots thereunto appertaining should 
 be filled up above the level of the street; and that all frame buildings below 
 the level of the brick pavement or the street should be raised up and under¬ 
 pinned with brick or stone. 
 
 MANUFACTORIES INJURIOUS AND DANGEROUS TO HEALTH. 
 
 Since section 6 of Ordinance 15, 1797, certain provisions in regard to these 
 manufactories have been carried for many years in the codes. Some of these 
 provisions date from early times. In general they apply to the manufacture of 
 substances at or during the preparation of which offensive odors are given off, 
 such as the preparation of roofing materials, the manufacture of varnish, the 
 grinding of bones, the distillation of turpentine, the manufacture of soap and 
 
70 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 candles, and the manufacture of various acids, bleaching substances, pigments 
 of lead, in the process of which it is necessary to bum horns, blood, bones, 
 etc. All these activities were allowed, but under restrictions, usually not within 
 a certain number of feet of dwellings and by permission. 
 
 Under ordinance of April 7, 187.1, it was provided that no slaughter or hide 
 house should afterwards be erected within the city limits. 
 
 According to the ordinance of May 25, 1893, no persons were henceforth to 
 be allowed to erect or establish within the city limits any poudrette works, 
 glue factories, or establishments for the purpose of rendering grease, dead ani¬ 
 mals, or animal offal, or stock yards for receiving, feeding, and offering for 
 sale live stock. 
 
 GARBAGE. 
 
 By the ordinance of November 1821, it was required that household filth 
 of all premises be put out in the streets, lanes, or alleys adjoining, every Tues¬ 
 day, Thursday, and Saturday of each week, from the first of May to the first 
 of November, before 8 o’clock in the morning, in order that it might be removed 
 by the superintendents of the streets. 
 
 Housekeepers were required by the ordinance of April 2, 1853, to place all 
 offal, coal ashes, or dirt which might engender disease, in a box or other vessel 
 convenient of access to the garbage collectors. 
 
 The ordinance of June 17, 1886, required householders to provide suitable 
 containers for garbage and offal, and they were forbidden to throw such materials 
 into any street, market, or other public place. 
 
 Occupants of dwelling-houses, proprietors of boarding-houses, commission 
 houses, hotels, restaurants, and other places where garbage accumulates, and 
 owners, agents, and occupants of apartment or tenement houses were required 
 by the ordinance of May 20, 1919, to provide a sufficient number of receptacles 
 to contain all garbage which accumulated on the premises during the usual in¬ 
 terval between the collections of garbage. These receptacles were to be of metal, 
 water-tight, and provided with a tight-fitting metal cover, with a handle; they 
 were to contain not less than 3 nor more than 10 gallons and be so constructed 
 that the garbage could be easily removed; they were to be easily accessible to 
 the garbage collector; and they were to be kept covered continuously except 
 when being filled or emptied. It was declared unlawful to include with the 
 garbage any ashes, rubbish, or trash. It was further ordained that no dead 
 animal, offal, garbage, or putrescible matter of any sort was to be placed or 
 thrown on any public highway or in any public sewer, and that nothing likely 
 to produce nauseating, vile, or offensive smoke or vapors was to be burned. 
 
 HABITATIONS. 
 
 The ordinance of June 5, 1871, provided for an inspector of buildings. He 
 was to supervise the construction and repair of city buildings, look after the 
 condition of such private buildings as might be dangerous to persons and 
 property, and control the installation and building of boilers and steam-engines 
 and the placing of sheds, bay windows, telegraph poles, signs, awnings, and 
 frame buildings. 
 
 The ordinance of June 4, 1886, regulated dwellings, tenements, and lodging- 
 houses as follows: Every house or building used, occupied, leased, or rented 
 
DEVELOPMENT OF HEALTH DEPARTMENT AND HEALTH LAWS, ETC. 71 
 
 as a dwelling, tenement, or lodging-house was to have in every sleeping-room 
 which did not communicate directly with the external air a ventilating or tran¬ 
 som window with an opening or area of 3 square feet above the door leading into 
 the adjoining room, provided the adjoining room communicated with the ex¬ 
 ternal air, and also a ventilating or transom window of the same opening or 
 area communicating with the entry or hall of the house. Where this was im¬ 
 practicable, due to the situation of the room, the latter ventilating or transom 
 window was to communicate with an adjoining room which communicated with 
 the entry or hall. Every such house or building was to have in the roof at the 
 top of the hall an adequate and proper ventilator, of a form approved by the 
 inspector of buildings and the board of health. 
 
 The roof of every such house was to be kept in good repair so that it would 
 not leak, and all rain-water was to be so drained therefrom as to prevent its 
 dripping on the ground or causing dampness in the walls, yards, or areas. 
 
 These houses were to be provided with good and sufficient privies or water- 
 closets, not less than 1 to every 20 occupants, which could be used in common by 
 occupants of any two or more houses, provided the access was convenient and 
 direct and the number of occupants in the houses did not exceed the above pro¬ 
 portion. No privy well was to be allowed in or under or connected with any 
 such house except when unavoidable, in which case it was to be constructed in 
 such a situation and manner as the board of health might direct. In all cases 
 it was to be water-tight and so constructed that no offensive smell or gases could 
 escape. The yard or area was to be so graded that all water from the roof or 
 otherwise could flow freely from all parts of it into the street gutter. 
 
 The sleeping or resident portion of any building was to be at least 3 feet of 
 its height and space above the level of the sidewalk or curbstone of any ad¬ 
 jacent street. The floors were not to be damp by water from the ground, nor 
 were the rooms to be impregnated or penetrated by any offensive gas, smell, 
 or exhalation prejudicial to health. Overcrowding was forbidden, but no 
 figures were given. Every dwelling, tenement, and lodging house was to be 
 kept clean and free from any accumulation of filth, garbage, and other matter 
 in or on them or in the yards, courts, areas, passages, or alleys connected with 
 or belonging to them. The owner or lessee of any dwelling, tenement, or lodging 
 house was required to cleanse thoroughly all the rooms, passages, stairs, floors, 
 windows, doors, walks, ceilings, and privies to the satisfaction of the board 
 of health, as often as it was deemed necessary, and was to whitewash the walls 
 and ceilings thereof at least once a year. 
 
 Secure foundations and construction of buildings were provided for in the 
 ordinance of October 23, 1891, which dealt at length with the thickness of walls 
 and the strength of structure for buildings of various heights and the details 
 of structure in regard to fire prevention. 
 
 In 1908, all the previous building laws were repealed and for them was 
 substituted a comprehensive building code, which goes into great detail con¬ 
 cerning structure, space, and position of private and public buildings. 
 
 This code prescribes that no tenement or apartment houses may be built on 
 any lot facing a street less than 40 feet wide; that there must be a space 
 of from 10 to 25 feet, according to the number of stories, between such houses 
 and other buildings within a block; that they are not to cover more than 80 
 
72 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 per cent of a lot bounded by two intersecting streets and must have in the rear, 
 when erected on an interior lot, a yard extending the entire width of the lot; 
 that the height must not exceed the width of the widest street upon which they 
 stand by more than one-half; and that the basement story must not be less 
 than 8 feet in the clear and all other stories not less than 9 feet in the clear. 
 In tenement and apartment houses, every court, entirely inclosed by build¬ 
 ings, onto which windows open from living rooms, is to have minimum dimen¬ 
 sions both in area and width, varying from 100 square feet in area and 6 feet 
 in width in two-story buildings to 1,600 square feet in area and 24 feet in 
 width in ten-story buildings. Suitable provisions are made for passages, stair¬ 
 ways, and ventilating shafts for toilets, kitchens, pantries, cellars, basements, 
 and the like; for the size of apartments and rooms; and for access to stair¬ 
 ways and fire escapes. Every one-family apartment is to contain not less than 
 two rooms, one of which is not to be less than 120 square feet in floor area, and 
 neither of which is to be less than 70 square feet in area. There shall not be 
 less than 400 cubic feet of air-space for every person over 12 years of age and 
 200 cubic feet of air-space for every child under 12 years of age occupying a 
 room. Every apartment must have a sink with running water and a separate 
 water-closet in a separate apartment within each apartment. On every floor 
 of a tenement or apartment house providing apartments for families, there 
 must not be less than one water-closet for each family. Hallways must be 
 ventilated by skylights in the top story of apartments and by windows. All 
 living rooms, including all rooms except bath-rooms, water-closets, and pantries, 
 are to be lighted and ventilated by windows opening directly into the street, 
 alley, court, or yard. The total area of such windows must equal one-tenth of 
 the floor area of the room, and every room must have at least one window not 
 less than 12 square feet in area, with its top not less than 7 feet 6 inches above 
 the floor. All bath-rooms, water-closets, and pantries must be lighted and ven¬ 
 tilated by windows not less than 3 square feet in area and opening directly onto 
 a street, alley, open court, or shaft. These windows are to be so constructed that 
 the top halves of the windows may be entirely opened for the passage of out¬ 
 side air. No paper shall be put on the walls of a room until all former wall paper 
 has been removed and the walls and ceilings thoroughly cleaned. Cellar walls 
 and ceilings must be thoroughly whitewashed or painted a light color at least 
 once a year. Every apartment is to have at least one chimney-flue for stove 
 connections. The alterations, repairs, and changing of other buildings into tene¬ 
 ment or apartment houses may only be made under the supervision of the 
 inspector of buildings. Tenement and apartment houses erected prior to the 
 date of this code were ordered to be changed partially or totally to conform 
 with all the provisions concerning tenement or apartment houses. 
 
 Provisions in regard to lodging-houses and hotels apply to those erected after 
 the date of the code. These provisions follow very closely those which govern 
 tenement and apartment houses, but they are somewhat more exacting. Every 
 sleeping-room in a hotel or lodging-house must have not less than 700 cubic feet 
 of air-space for every person, every bedroom is to be lighted and ventilated by 
 a window or windows, opening directly upon a street, alley, court, or yard, 
 and at least one window in every such room is to be not less than 12 square 
 feet in area. Every lodging-house which accommodates more than 20 persons 
 
DEVELOPMENT OF HEALTH DEPARTMENT AND HEALTH LAWS, ETC. 73 
 
 must have one isolation room on the top floor with not less than 1,000 cubic 
 feet of air-space and with a separate sealed olf water-closet. Ventilation is to 
 be by means of a skylight, and the walls, roof, and ceiling are to be water-proof. 
 The bath-rooms must have windows of an area not less than one-eighth of the 
 floor area in the isolation room and not less than 3 square feet in the water- 
 closet. These windows must open on a street, alley, or yard. 
 
 All buildings must have suitable window areas, and they shall be so placed 
 upon their respective sites and their window construction shall be so arranged 
 that the proper amount of light and ventilation may be secured in all parts 
 and subdivisions of such buildings and for all the purposes of their occupation, 
 all as may be determined by the inspector of buildings. 
 
 In two-story houses, the interior room or rooms on the second floor not open 
 to the air and light by direct access to areas or courts are to be provided with 
 skylights, each of an area not less than 5 per cent of the floor area of the room 
 in which the skylight is located and arranged to provide proper ventilation as 
 well as light. 
 
 The inspector of buildings must receive applications, examine plans, and 
 grant permits for the erection, construction, alteration, repair, and removal of 
 buildings. He must inspect or cause to be inspected all works of construction, all 
 walls, dangerous buildings, and all buildings, public and private, and all por¬ 
 tions and parts thereof. He must determine the application and interpreta¬ 
 tion of the code and pass upon every question relating to the method of con¬ 
 struction or materials used in the erection, repair, or alteration of buildings. 
 For these purposes he may make rules and regulations. 
 
 PLUMBING. 
 
 The ordinance of October 22, 1883, granted the power to the commissioner of 
 health with the mayor to appoint annually an inspector of plumbing for 
 sanitary purposes, who shall be under the direction and supervision of the 
 board of health. The inspector must be a practical plumber and not interested 
 either directly or indirectly during the holding of his office in the business of 
 plumbing or furnishing plumbing materials. This ordinance provided that no 
 pipe then used or thereafter to be used to drain any matter, liquid or solid, from 
 any building used for habitation or occupancy by man, into any well or sink 
 used for the reception of any substance except pure water, or into any public 
 sewer, or into any stream, or into any harbor, should be put up, constructed, 
 altered, or repaired without first obtaining a permit therefor from the board 
 of health. Construction so authorized could not be undertaken at a date earlier 
 than that named in the application for such permit, and all such plumbing 
 work, as above referred to, was to be done subject to the supervision of the 
 inspector of plumbing and in strict conformity to such orders and directions as 
 might be prescribed by the inspector with the approval of the board of health. 
 Whenever such work was completed in a manner satisfactory to the inspector, he 
 was required to give to the owner or owners of the premises a certificate of 
 inspection and approval. 
 
 In 1898, the commissioner of health published a pamphlet of rules and regu¬ 
 lations comprising 44 sections, dealing with plumbing and plumbing inspec¬ 
 tion and based upon the above law. While these regulations for the most part 
 
74 
 
 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 have to do with the administrative details in the carrying out of the ordinances, 
 they are important from the standpoint of construction in that they give 
 definite instructions regarding the size and laying of pipes, the character of 
 joints, and the like. They make obligatory the use of traps and fresh-air inlets 
 and prescribe their situation. All these provisions conform in general with 
 the accepted usages of that date. They forbade the construction of water- 
 closets in sleeping-rooms, or in any apartment or vault not in direct communi¬ 
 cation with the outside air by means of a window or air-shaft having an area 
 of at least 4 square feet for the admission of fresh air and light. For water- 
 closets situated outside of buildings, the use of straight non-absorbent hoppers 
 without flush-tanks was permitted. The connection of waste pipes from bath¬ 
 tubs, wash-stands, and sinks with the trap of a water-closet was forbidden. 
 Except as mentioned, all water-closets were required to have separate flush tanks 
 holding at least 4 gallons of water. The use of long, straight hoppers, or offset 
 hoppers, or pan and plunge closets, was forbidden in any building. Water- 
 closets and urinals could not be connected directly with or flushed from water- 
 supply pipes, but they must be flushed from separate systems on every floor, 
 the water of which is used for no other purpose. Safes and refrigerators are to 
 be drained by special pipes not connected with the house drain or main sewer. 
 Wooden laundry wash trays, or kitchen or other sinks were prohibited inside 
 buildings. 
 
 In the building code of 1908, there is a section on plumbing comprising 23 
 pages. In this code, all plumbing and drainage are placed under the supervision 
 of the commissioner of health, but he is required to furnish the inspector of 
 buildings with a copy of every permit allowing any plumbing work, whether 
 of new installation, alteration, or repair. The inspector of buildings and the 
 commissioner of health must formulate rules and regulations consistent with 
 the ordinances for the execution of plumbing work. This section of the build¬ 
 ing code includes substantially the points covered by the regulations of the 
 commissioner of health of 1898, but it amplifies them and provides more 
 specifically for the details of construction. 
 
 In succeeding ordinances, the powers granted to the commissioners of health 
 in regard to nuisances had expanded so as to cover all forms of nuisances 
 arising from defective surface and roof drainage, the collection of standing 
 water in utensils within and without dwellings and other buildings, and the 
 collection of rubbish, the presence of weeds, grass, cans, bottles, and the like. 
 Orders to abate nuisances have been issued directly by commissioners, inspectors, 
 health wardens, and police officers. Such orders have gone primarily to oc¬ 
 cupiers of dwellings or buildings, and if not obeyed, to the owners or to their 
 agents. 
 
 FOODS. 
 
 The ordinances of March 30, 1797, and July 17, 1797, provided that all 
 salt beef, pork, and fish brought into the city be made merchantable, sound, 
 and fit for use, and authorized inspection of these articles. 
 
 The clerks of the markets were empowered by the ordinance of March 25, 
 1805, to prevent the sale of all blown, stuffed, unsound, or unwholesome pro¬ 
 visions and to regulate the weighing of them by standard scales. 
 
DEVELOPMENT OF HEALTH DEPARTMENT AND HEALTH LAWS, ETC. 75 
 
 On May 30, 1855, an ordinance was passed, forbidding, under a penalty of 
 $20 fine, the “adulteration of milk offered for sale or sold in Baltimore by mixing 
 with it water, chaulk, or any drug or other article whatsoever.” 
 
 In 1879, another ordinance was passed, making it unlawful to mix water, 
 any drug, or other article with milk offered for sale, but, as was the case with 
 the ordinance of 1855, no adequate provision was made by the city government 
 for its enforcement. 
 
 Bv the ordinance of May 16, 1894, amplified by the ordinance of March 19, 
 1904, it was made unlawful to sell, expose for sale, or to have upon his or her 
 premises, store, stall, stand, vehicle, or elsewhere, from or in which milk or any 
 other food products are sold or delivered, any impure, adulterated, sophisticated, 
 or unwholesome milk or other food products, or any tainted, unsound, rotten, or 
 partly decomposed fish, fruit, vegetables, meat, or any food product that is kept 
 fresh by salicylic or boracic acid or other preservative. It was the duty of the 
 commissioner of health to have inspected milk, meat, fish, and vegetables 
 wherever such articles are sold, kept, or offered for sale in the city and to obtain 
 samples of milk and all other food products whose qualities are to be determined 
 by chemical and microscopical examination and to make the necessary rules 
 and regulations governing these products. Provision was made in the ordinance 
 of 1894 for the appointment of the chemist and three inspectors. According 
 to the milk standards set by this ordinance, there could be sold in Baltimore 
 only pure, unadulterated, unsophisticated milk, the natural product of healthy 
 cows, not deprived of any part of its cream, and to which no additional liquid 
 or solid or preservative had been added, and which at 60° F. would have a 
 specific gravity of not less than 1.029, not less than 12 per cent of total solids, 
 and not less than 3 per cent of butter fat. All milk sold, received, kept, offered 
 for sale, or delivered in the City of Baltimore, could not in any particular be 
 under the standard described, without being considered impure, adulterated, 
 sophisticated, or unwholesome. Nothing in this ordinance was to be construed 
 to prevent the sale of skim milk or buttermilk, provided they be sold as such 
 and in every instance the purchasers be notified of their true character. 
 
 The ordinance of April 21, 1896, regulated the ventilation, flooring, and 
 cleanliness of cow stables. The floors were to be of cement or other non¬ 
 absorbent materials, with grades and channels to carry off drainage connected 
 with the public sewer, if one abutted the premises. The stables for cows for 
 dairy purposes were to have sufficient troughs and boxes for feeding and a 
 covered water-tight receptacle outside of the building for the reception of dung 
 or other refuse. No privy, cesspool, urinal, inhabited rooms, or workshops were 
 to be located within any building or shed used for stabling cows for dairy pur¬ 
 poses or for the storage of milk or cream; nor was any fowl, hog, horse, sheep, 
 or goat to be kept in any rooms used for such purposes. The stalls for such 
 cows were to be not less than 4 feet in width. The premises on which cows were 
 to be kept for dairy purposes were to be kept thoroughly clean and in good 
 repair, and well painted and whitewashed at all times. Every cow was to be 
 cleaned and properly fed and watered each day. This ordinance made compul¬ 
 sory the prompt reporting to the health department not only of the occurrence 
 of contagious and infectious diseases among cows, but of cases of Asiatic cholera, 
 croup and diphtheria, measles, scarlatina, small-pox, and typhus and typhoid 
 
 6 
 
76 
 
 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 fevers upon the premises with milch cows, or where milk is handled or offered 
 for sale. Milk from premises where there were cases of any of these or other 
 infectious diseases could not be sold nor given away until the commissioner of 
 health deemed it safe. Persons connected with dairying and milk handling were 
 forbidden to enter such premises. The tuberculin test for milch cattle within 
 the city was required. 
 
 The sanitary conditions under which milch cattle could be kept were made 
 more stringent by the ordinance of May 13, 1902, which required non-absorbent 
 floors in stables, with proper drainage and more air-space and range for cows. 
 
 By the changes in the code of 1906, the city government was given extensive 
 powers to control food products. 
 
 In 1908, a sweeping ordinance was passed, giving the health department 
 greater control over the milk-supply, requiring permits for handling milk, 
 making provision for dairy-farm inspection, excluding for sale the milk of 
 slop-fed cows, the cleansing of utensils, the regulation of conditions under 
 which milk could be sold, and raising the standard for total solids to 12.5 per 
 cent of butter fat to 3.5 per cent. 
 
 The ordinance of June 1, 1917, amended the former milk ordinances so as 
 to give the commissioner of health complete control over the milk and the 
 milk-supply from the farm to the table. To this end it reaffirmed the provision 
 for dairy inspection, permits for shipping milk to the city, and permits for the 
 sale of milk within the citv. It also established bacterial standards for raw milk 
 and rules and regulations for the pasteurization, cooling, labeling, and bottling 
 of milk sold within the city and for the cleansing and sterilization of milk cans, 
 bottles, pasteurizing apparatus, and all other utensils connected with the milk 
 industry. All the raw milk sold must come from non-tuberculous cows and 
 must not have a bacterial count of over 50,000 per cubic centimeters. Selected 
 pasteurized milk and selected pasteurized cream must come from tuberculin- 
 tested cows and contain not over 200,000 bacteria per cubic centimeters before 
 pasteurization and not more than 30,000 bacteria per cubic centimeters after 
 pasteurization prior to delivery. Standard milk pasteurized must contain not 
 more than 100,000 bacteria per cubic centimeters after pasteurization and prior 
 to delivery and not more than 1,500,000 per cubic centimeters before pasteuriza¬ 
 tion. “ Pasteurized milk shall be milk which has been uniformly heated to a 
 temperature between 140° F. and 150° F. and maintained at that temperature 
 for not less than 30 minutes and cooled immediately to a temperature of 45° 
 or less.” Milk and cream falling below the requirements for standard milk pas¬ 
 teurized or standard cream pasteurized are called “ below-standard milk ” and 
 may be sold only under the authority of the commissioner of health and for only 
 such purposes and in accordance with such restrictions and regulations as may 
 be prescribed by him. 
 
 III. STATE OF MAKYLAND. 
 
 After the passage of the quarantine laws previously alluded to, nearly 100 
 years elapsed before the passage by the State Legislature of any State laws, 
 with the exception of those establishing the State vaccine institute or agency in 
 1864, that influenced either directly or indirectly the public-health administra¬ 
 tion of Baltimore. The law establishing the State Board of Health was passed 
 in 1874. 
 
DEVELOPMENT OF HEALTH DEPARTMENT AND HEALTH LAWS, ETC. 77 
 
 CONTAGIOUS AND INFECTIOUS DISEASES. 
 
 In 1882, the same year in which the city ordinance required the reporting 
 to the commissioner of health by physicians and others of cases of certain com¬ 
 municable diseases, the State Legislature passed a law empowering the health 
 authorities of any city or town or the justice of peace of any county of Mary¬ 
 land, on the certificate of a qualified medical practitioner, to order “ the cleans¬ 
 ing and disinfecting of any house or part thereof, and any articles therein 
 likely to retain infection,” when in their opinion these acts would tend to check 
 or prevent infectious diseases, and where the owner or occupier of such a house 
 was unable to carry out these requirements, the local authorities were empowered 
 to carry out such procedures at the public expense. The law further provided 
 that: 
 
 “ Any person who, while suffering from any dangerous infectious disorder, wilfulty ex¬ 
 poses himself or herself, without any proper precautions against spreading said dis¬ 
 order in any street, public place, shop, inn, or public conveyance, without previously 
 notifying the owner, conductor, or driver that he is so suffering, or being in charge of 
 any person so suffering, so exposes such sufferer, or gives, lends, sells, transmits, or 
 exposes, without previous disinfection, any bedding, clothing, rags, or other things which 
 had been exposed to infection from any such disorder, shall be liable to a penalty not 
 exceeding $500, or imprisonment not exceeding twelve months, or both, in the discre¬ 
 tion of the circuit court for the county or criminal court of Baltimore. Any person who 
 carelessly carries children or others infected with infectious diseases or who knowingly 
 introduces infected persons into other person’s premises, or permits children under his 
 or her care to attend any school, theater, church or other public place where they 
 will be brought in contact with others, shall be liable to a penalty not exceeding $100 
 for each and every offence.” 
 
 Owners or drivers of public conveyances were required- to disinfect sucli con¬ 
 veyances as approved by the local health authority, after conveying in them 
 anyone suffering from any dangerous or infectious disorder or the corpse of 
 anyone who has died from any such disorder. It was forbidden to let for hire 
 any house, room, or part of a house in which any person had suffered from a 
 dangerous or infectious disorder without having it and all articles therein liable 
 to retain infection disinfected to the satisfaction of a qualified medical prac¬ 
 titioner. Any health officer or justice of the peace was given the power to cause 
 to be removed or buried at public cost the body of anyone who had died of 
 infectious diseases which was retained in a room in which persons were living 
 or sleeping, or any dead body which was in such a state as to endanger the health 
 of the inmates of a house or room. Notification of cases of infectious diseases 
 was not required by State law until 1898. 
 
 By act in 1904, the State Board of Health was required to keep a register of 
 all persons in the State known to be affected with tuberculosis. The superinten¬ 
 dent or other person in charge of any hospital, dispensary, school, reformatory, 
 or other institution which derived the whole or any part of its support from the 
 public funds of the State of Maryland, or of any city, town, or county of the 
 State, having in charge or under care or custody any person or persons suffering 
 with pulmonary or laryngeal tuberculosis, w r as to report that fact to the State 
 Board of Health within 48 hours after the recognition of such disease. Any 
 physician who knew that any person under his professional care was afflicted 
 with pulmonary or laryngeal tuberculosis was required to transmit to the State 
 
78 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 Board of Health within 7 days a report of the case on blanks provided by the 
 State Board of Health. The same law provided that apartments occupied by any 
 consumptive were to be disinfected by the board of health of the city, town, or 
 county when they had been vacated by the death or removal of the consumptive 
 occupant. Persons were forbidden to permit anyone, for hire or otherwise, to 
 occupy such apartments before such disinfection. By the same act, persons af¬ 
 fected by any disease, the infective agent of which is contained in the sputum, 
 saliva, or other bodily secretion or excretion, who might dispose of the sputum, 
 saliva, or other bodily secretion or excretion in a manner that might cause 
 offence or danger to any person or persons occupying the same room or apart¬ 
 ment, house, or part of a house, were to be deemed guilty of a nuisance upon 
 complaint. It was to he the duty of the commissioner of health or of any local 
 health officer receiving such complaint, if the complaint be substantiated, to 
 serve notice upon the person so complained of and to require him to dispose 
 of his sputum, saliva, and other bodily secretion or excretion in such manner as 
 to remove all reasonable cause of offence or danger. It was made the duty of 
 the physician attending any case of pulmonary or laryngeal tuberculosis to 
 provide for the safety of all individuals occupying the same house or apart¬ 
 ment, and if no physician he in attendance upon such a patient, this duty 
 should devolve upon the local health authority. The local health authority was 
 required to furnish to physicians reporting any case of pulmonary or laryngeal 
 tuberculosis a printed report, prepared and authorized by the State Board of 
 Health, setting forth the precautions necessary or desirable to be taken on the 
 premises of the said tuberculosis case. If the attending physician were unable or 
 unwilling to take the procedures and precautions specified, these duties then 
 were to devolve upon the local health authority. Physicians who carried out 
 the procedures recommended were to receive on the order of the local board of 
 health a fee of $1.50, to be paid by the State Board of Health. To such physi¬ 
 cians an order on the State Board of Health for materials (disinfectants, spu¬ 
 tum-cups, etc.) were to be issued for the prevention of the spread of the disease. 
 
 By an act of 1894, it was provided that “ if at any time within two weeks 
 after the birth of any infant, one or both of its eyes, or the eyelids, be reddened, 
 inflamed, swollen, or discharging pus, the midwife, nurse, or person other than 
 a legally qualified physician, in charge of such infant, shall refrain from the 
 application of any remedy for the same, and shall immediately report such con¬ 
 dition to the health commissioner or to some legally qualified physician in the 
 city, county, or town wherein the infant is cared for.” 
 
 In 1911, the legislature authorized the State Board of Health to provide 
 the “ Pasteur antirabic treatment 99 for the prevention of hydrophobia, free of 
 charge to those unable to pay for it. 
 
 VACCINATION. 
 
 In 1864, it was required of every practicing physician in the State that he 
 vaccinate all children in the circuit of his practice who might be presented to 
 him for vaccination within one year after birth, if such children be in proper 
 condition for such service, and all other persons, not previously effectually 
 vaccinated, who might request such service from him. There was a penalty of 
 $5 for non-observance of this duty. Physicians were also forbidden under 
 
DEVELOPMENT OF HEALTH DEPARTMENT AND HEALTH LAWS, ETC. 79 
 
 penalty of not less than $100 nor more than $500 to use any virus defective in 
 its nature by having passed through a scrofulous system, or by having been 
 taken from one laboring under any disease of the skin, chronic sore, or other 
 febrile or other disease, or any crust which, during the progress of the vaccine 
 disease, was punctured or had sustained other injury. Every patient or guardian 
 was required to have his or her child vaccinated within 12 months after its birth, 
 if it was in proper condition, or as soon thereafter as practicable, and any other 
 person under his or her control or care was to be vaccinated prior to November 1 
 of each year. School-teachers were forbidden to receive into schools, as scholars, 
 persons without the certificate of some regular practising physician that such 
 applicants for admission into the schools have been duly vaccinated. By the 
 legislative act of 1867, the State vaccine agent was required to take all steps 
 necessary to reproduce from the cow true vaccine virus for the use of physicians 
 residing and practising medicine and surgery in the State. He v r as forbidden 
 to furnish such virus more than four removes from the cow if practicable and 
 none that had not been produced under his own supervision and direction, pro¬ 
 vided that he might use and furnish virus furnished him by any physician 
 intrusted by him to procure it, such virus not to be taken from the arm of a 
 child less than three months old. 
 
 MEDICAL PRACTICE. 
 
 The first State act concerning medical practice, which was passed in 1888 
 and amended in 1892, placed the examinations and medical qualifications in 
 the hands of two separate examining boards; one represented the Medical and 
 Chirurgical Faculty and the other the Maryland State Homeopathic Society. 
 
 REGISTRATION AND LICENSES. 
 
 By act of the legislature of 1910, all midwives in practice previous to July 
 1, 1910, were required to register with the local register of vital statistics, and 
 no one was allowed to practice as midwife after this date without license granted 
 after examination by the State Board of Health. 
 
 By 1910, the legislature had passed laws regulating the admission into the 
 occupations of pharmacy, nursing, undertaking, plumbing, and barbering. 
 
 REGISTRATION OF BIRTHS AND DEATHS. 
 
 The first State law requiring the registration of births and deaths was passed 
 in 1898. By this law the Secretary of the State Board of Health was made the 
 registrar of vital statistics and became responsible for the methods and forms 
 of registration and for the tabulation and preservation of the facts. Local 
 health officers of counties, towns, and cities were made local registrars, and 
 physicians became subregistrars and were directed to make returns to the local 
 resristrars of births and deaths on suitable forms furnished by the secretary of 
 the State Board of Health. Death certificates of individuals dying without 
 the attendance of physicians were required to be made out by undertakers, 
 coroners, or others having knowledge of them. Midwives were allowed to make 
 returns of births if no physicians were in attendance. Notifications to the local 
 registrar of births and deaths were required of parents, of householders, and of 
 
80 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 the superintendents of workhouses, houses of correction, prisons, hospitals, 
 reformatories, almshouses, and other institutions, and by masters or other 
 commanding officers of ships or other vessels. Whereas, under this system, the 
 originals of birth and death certificates were required to be sent to the secretary 
 of the State Board of Health as registrar of the State, this had never been made 
 to apply to the City of Baltimore. With the revision of the registration laws of 
 1900, it was provided that in the case of births and deaths occurring within the 
 City of Baltimore, the State registrar would not require the return to him of 
 the original certificates of births and deaths, but only such transcripts, tables, 
 figures, and compilations as might seem to him advisable or necessary. Under 
 this provision, the State registrar was to be furnished by the commissioner of 
 health either with duplicates or with punched cards. The enactment of 1904 
 required that still-born children be registered under both births and deaths, and 
 a certificate of both birth and death was to be filed with the local registrar in 
 the usual form and manner; the certificate of birth to contain in the place for 
 the name of the child the word “ still-birth” and the death certificate to 
 enter the cause of death as “ still-born.” A burial or removal permit of the 
 usual form was required. Under this law, midwives were not to be allowed to 
 sign certificates of death for still-born children. . 
 
 The State Lunacy Commission, with broad powers, was established by an 
 act of 1886. 
 
 CHILD LABOR LAWS. 
 
 By an act of legislature of 1888, amended in 1892, the employment of 
 children under 16 years-of age in any manufacturing or mercantile business for 
 more than 10 hours a day was forbidden. The law of 1896 forbade the employ¬ 
 ment of children under 12 years of age in any mill or factory within the State, 
 but this act did not apply to 16 counties of the State, including Baltimore 
 County. According to the act of 1912, as amended in 1914, 1916, 1918, and 
 1920, children under 14 years of age were not permitted to work in any industry 
 and could not work for hire in any business or service whatsoever during school 
 hours. Boys under 12 and girls under 16 were not allowed to sell newspapers. 
 Children under 16 years of age were entirely excluded from factories in which 
 machines were operated; chemical, paint, and dye works; heavy work in the 
 building trades; manufactories involving the escape of poisonous gases; tobacco 
 factories; work in tunnels and mines; and theatrical and concert-hall appear¬ 
 ances. No child under 18 years of age was permitted to work in or about blast 
 furnaces, docks, and wharves, or with electric wiring. They were forbidden to 
 run elevators, to work with dynamos, to oil machinery in motion, or to take part 
 in the operation of polishing or buffing wheels. They could not be employed as 
 railroad hands, trainmen, telegraphers, pilots, firemen, or engineers, or in 
 connection with explosives, in the manufacture of phosphorus matches, or in 
 the manufacture or distribution of alcoholic liquors. No minor could be 
 employed in connection with a barroom. 
 
 GENERAL LABOR LAWS. 
 
 Between 1904 and 1914, the legislature enacted health laws, governing labor 
 in factories, workshops, and dwellings, and designed to insure adequate sani- 
 
DEVELOPMENT OF HEALTH DEPARTMENT AND HEALTH LAWS, ETC. 81 
 
 tary surroundings, to guarding against individuals with communicable diseases, 
 and to protect child labor. 
 
 By an act in 1896, the proprietors or owners of retail, jobbing, or wholesale 
 stores, or any other place where female help was engaged for the purpose of 
 serving the public in the capacity of clerks or sales ladies were to provide a 
 chair or stool for each one of such female help or clerk. 
 
 The legislative enactment of 1884 provided that all factories, manufacturing 
 establishments, or workshops within the State were to be kept in a cleanly con¬ 
 dition and free from effluvia arising from any drain, privy, or other nuisance, 
 forbade overcrowding injurious to health of persons employed therein, and 
 required sufficient light and ventilation to render harmless, so far as prac¬ 
 ticable, all the gases, vapors, dust, or other impurities generated in the course 
 of the manufacturing processes or handicraft carried on therein which might 
 be injurious to health. 
 
 By an act of 1894, the manufacture or sale of clothing and other articles in 
 places or under circumstances endangering the public health was forbidden: 
 
 “ Any room or apartment which shall not contain at least 400 cubic feet of clear floor 
 space for each person habitually laboring in or occupying the same, or wherein the 
 thermometer shall habitually stand, during the hours of labor, at or above 80° F., be¬ 
 fore the first day of May or after the first day of October of any year, or wherein any 
 person suffering from a contagious, infectious, or otherwise dangerous disease or malady 
 shall sleep, labor, remain, or wherein, if of less superficial area than 500 square feet, 
 any artificial light shall be habitually used between the hours of 8 a. m. and 4 p. m., or 
 from which the debris of manufacture and all other dirt or rubbish shall not be re¬ 
 moved at least once in every twenty-four hours, or which shall be pronounced ill- 
 ventilated or otherwise unhealthy by any officer or board having legal authority so to 
 do, shall be deemed a place involving danger to the public health.” 
 
 By an act of 1896, it was unlawful— 
 
 “ for any person, agent, owner, or proprietor of a sweatshop or factory where four 
 or more persons are employed, to use coal oil, gasoline or other explosive or in¬ 
 flammable compound for the purpose of lighting or*heating in any form; any person, 
 agent, owner or proprietor violating the provisions of this section shall be guilty of a 
 misdemeanor, and on conviction thereof, to be fined by the court before whom such 
 conviction is had, for every violation, the sum of one hundred dollars and costs, and 
 stand committed until such fine and costs be paid. 
 
 “ The owner or owners of any such house or building used as a sweatshop or factory 
 where four or more persons are employed as garment workers, on other than the 
 first floor of such house or building, shall provide fire escapes for the same; and if 
 any owner or owners of any house or building so used fail to make or provide a fire 
 escape within six months after the passage of this act, upon conviction thereof shall 
 pay a fine of two hundred dollars, to be recovered as other fines in this State, or im¬ 
 prisonment in the city jail for sixty days, or both fine and imprisonment, in the discre¬ 
 tion of the court” 
 
 An act of legislature in 1910 required the proprietors and managers of shirt 
 factories in the State of Maryland to sprinkle the floors every morning with 
 water. 
 
 NUISANCES. 
 
 An act of 1886 gave the State Board of Health control over nuisances affect¬ 
 ing the water-supply of any city, town, or village. A similar act in 1888 made 
 it unlawful to pollute the ponds or streams used for obtaining ice, and forbade 
 the dumping from ships, scows, steamboats, and other vessels of any ballast, 
 
82 
 
 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 ashes, filth, earth, soil, oysters, or oyster shells in the Chesapeake Bay above 
 Sandy Point or in the waters of Herring Bay or in any river, creek, or harbor 
 Vithin the State below high-water mark. 
 
 FOOD. 
 
 The legislature in 1890 passed a broad act directed against the coloring, 
 staining, adulteration, or other sophistication of any article of food or drink, 
 mislabeling, and misbranding, and charged the State Board of Health with 
 enforcing the same, and at the same time gave it power over the inspection and 
 examination of all animal and vegetable food-stuffs, including milk. 
 
 INSPECTION. 
 
 The Live Stock Sanitary Board, established by an act of the legislature in 
 1888, was given oversight of contagious and infectious diseases in animals 
 and control over dairymen and others supplying milk to cities, and established 
 sanitary rules in regard to stables for cattle and buildings in which milk is 
 kept or sold. 
 
 These powers and duties were extended by the act of 1916, by which the whole 
 matter was placed under the State Board of Agriculture, with greatly increased 
 powers and duties in regard to the inspection of dairies and dairy cattle, milk, 
 creameries, cattle, and meat. 
 
 By an act of the legislature in 1880, amended in 1888, inspection was pro¬ 
 vided for the safety of buildings used for amusement, worship, and lodging in 
 the cities of the State. 
 
PART III.—PUBLIC HEALTH ADMINISTRATION OF 
 
 BALTIMORE. 
 
 Chapter V. —Public Health Measures 
 
 WITHOUT THE ClTY. 
 
 Development of quarantine laws and practices; The lazaretto and quar¬ 
 antine hospitals of the Port of Baltimore: Effectiveness of maritime 
 quarantine. 
 
 THE DEVELOPMENT OF QUARANTINE LAWS 
 
 AND PRACTICES. 
 
 In Baltimore the fight concerning the quarantine restrictions to be imposed 
 on the port centered about the question of yellow fever. Concerning small-pox 
 and probably typhus fever there was no controversy. Was yellow fever con¬ 
 tagious or non-contagious; was it imported or of local origin? Upon the 
 decision of these questions depended the quarantine policies and the mercan¬ 
 tile interests of the young city. The fight over these questions lasted until 1825. 
 The Philadelphia, New York, and Boston ports held to the official British 
 doctrine that the disease was contagious and was imported. These cities, 
 Philadelphia in particular, developed stringent quarantine laws against this 
 disease. In Charleston, the southern port of greatest importance, it would 
 seem that the contrary view was held, for the celebrated Dr. Ramsey (31), of 
 Charleston, in a letter to Dr. Miller, of New York, under date of November 18, 
 1800, stated that— 
 
 “ Disputes about the origin of yellow fever, which have agitated the Northern States, 
 have never existed in Charleston; there is but one opinion among the physicians and 
 inhabitants, and that is that the disease was neither imported nor contagious. It was 
 the unanimous sentiment of the medical society, who, in pursuance of it, gave their 
 opinion to the Government last summer, that the rigid enforcement of the quarantine 
 
 laws was by no means necessary on account of the yellow fever.My private 
 
 opinion is that the yellow fever is a local disease, originating in the air of Charleston.” 
 
 At the time of the outbreak of the great yellow-fever epidemic in Philadelphia 
 in 1793, it was not questioned by any authority, north of Charleston, South 
 Carolina, at least, that the disease was imported and not of local origin. 
 Deveze (32), the resident physician of the yellow fever hospital of Philadelphia, 
 published a paper in December of that year in which he laid down the doctrine 
 that yellow fever is not contagious, but this apparently attracted no attention. 
 Deveze came to Philadelphia from the West Indies, shortly before or during 
 the time of the yellow-fever epidemic, and as we have already learned through 
 Lind, some physicians at least in the West Indies denied that this disease is 
 carried by contact. Dr. Benjamin Rush, with the rest of the leading physicians 
 of Philadelphia, then believed the disease to be imported and spread by personal 
 contact. As we have already seen, the governor of Maryland instituted as vigor¬ 
 ous a quarantine as he could against Philadelphia at that time, and this quaran- 
 
 83 
 
84 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 tine was maintained not only by the governor but by the local authorities of 
 Baltimore each succeeding year until 1797. Dr. John B. Davidge, of Baltimore, 
 is commonly given the credit for the first printed enunciation in the United 
 States that yellow fever is not contagious. This statement was first printed in 
 the Federal Gazette of Baltimore on November 30, 1797, nearly eight months 
 after the passage of the first health ordinance of the City of Baltimore. In 1798, 
 Dr. Davidge (33), published A Treatise on the Autumnal Endemical Epi- 
 demick of Tropical Climates, Vulgarly Called the Yellow Fever, in which he 
 defined the disease as follows: 
 
 “ The yellow fever, synonymous with la maladie de Siam, or la fevre matelotte of the 
 French and vomito prieto of the Spaniards, is the majority or acme, as the intermit¬ 
 tent is the embryo, of the remittent bilious fever; it is to the common bilious what the 
 confluent is to the common mild smallpox; they are in kind the same; a specific difference 
 only exists between them. It is conceived in the same matrix and quickened by the 
 same sun, it is indigenous to America and to all other warm climates, it is the very out¬ 
 let to Americans and Britons, from life to the grave.” 
 
 Davidge suggested that as the malarial fevers, including yellow fever, are 
 admittedly caused by marsh effluvia, and as the latter appear to be decompo¬ 
 sition products of both vegetables or of water, and, in the decomposition of 
 either, hydrogen is produced in considerable quantities, and as this is what 
 occurs in the conditions under which marsh effluvia are generated, the hydro¬ 
 gen set free in this decomposition is the “ peccant agent.” At that time and for 
 years previous, intermittent, remittent, and bilious fevers and dysentery com¬ 
 monly prevailed in the summer and autumn at Fell’s Point and to a certain 
 extent along the low grounds contiguous to Jones Falls and the basin. Fell’s 
 Point, however, was always the place of the greatest intensity of these fevers, and 
 it was at Fell’s Point that yellow fever always started. Alluding to the yellow- 
 fever epidemic in Baltimore in 1797, Dr. Davidge, who was a member of the 
 committee on health sent to Fell’s Point to investigate the disease, stated that 
 the common bilious fever prevailed there as usual from June and that a little 
 later “ the disease raised from the grade of bilious to yellow fever and mounted 
 its chariot of death and drove furiously through the streets.” He held, therefore, 
 that the malarial fevers, particularly bilious remittent fever, and yellow-fever 
 were one and the same disease, due to the same cause, the effluvia of the decayed 
 vegetable material, and of local origin. He did not deny that either of these 
 diseases could be imported, but he did assert that yellow fever, when it occurred 
 in Baltimore, was not imported. He held that just as the bilious fevers were 
 caused by decayed vegetable material and were not contagious, and as contagious 
 diseases were due solely to human effluvia, so diseases caused by effluvia of 
 decayed vegetable material are endemic and are the antitheses of the contagious 
 diseases. 
 
 During the yellow-fever epidemic in Bhode Island in 1797, Dr. William 
 Senter (34), the leading physician of Newport, and a member of a committee 
 of physicians appointed to advise the authorities concerning the nature and 
 prevention of this disease, contended that yellow fever was not contagious and 
 was of local origin and not imported. His views were, however, strenuously 
 opposed by his colleagues. 
 
 Nathaniel Potter, in the preface of his Memoir on Contagion (23), published 
 in 1817, while giving full credit to Davidge for being first to announce in print 
 
PUBLIC HEALTH ADMINISTRATION OF BALTIMORE 
 
 85 
 
 that yellow fever was indigenous and was not contagious, stated that he, himself, 
 reached these conclusions in the summer of 1793, while practicing in Caroline 
 County, Maryland, and quoted from a letter which he wrote to Dr. Benjamin 
 Rush, of Philadelphia, his preceptor, saying— 
 
 “ that those various forms of bilious fever unquestionably owe their existence to the 
 putrefaction of matters on the surface of the earth after an uncommonly wet spring 
 followed by the driest and hottest summer that can be remembered by the oldest 
 inhabitants. With all possible deference to your superior judgment, I can not prevail 
 upon myself to believe that any fever arising from vegetable decomposition is conta¬ 
 gious. The origin I have assigned to the epidemic of your city is the only one that is 
 physically possible, and, therefore, you place your adversaries on equal ground with 
 you by acknowledging the fever contagious. Deny the existence of contagion as un- 
 philosophical, and you cut them off from every source. If we admit one of the fevers 
 from marsh effluvia to be contagious we are bound (a priori) to admit them all to be 
 so, intermittent and dysenteric.” 
 
 Potter further stated that when Dr. Rush was writing in April 1794, on the 
 epidemic of the preceding year, he proposed to Potter to introduce into his 
 work that part of the above letter which described the symptoms and treatment 
 of the epidemic in Caroline County. To this Potter consented, provided Rush 
 would also print the sentiments expressed, so far as they regarded contagion. 
 Rush declined to do this, says Potter, on account of his former belief “ that all 
 diseases arising from marsh miasmata were contagious in a degree proportionate 
 to their malignity and that the opposite doctrine was untenable.” Believing 
 that he was the only person in America who denied the contagion of yellow 
 fever and deeply impressed that this opinion could be sustained by the facts, in 
 the summer of 1795 Potter selected this topic for his inaugural thesis at the 
 next commencement. He was dissuaded from this, however, by Dr. Wistar, who 
 entreated him on the score of policy and expediency to select some other subject. 
 
 In regard to the history of yellow fever in this country and the question as 
 to its contagious character, one of the most important contributions was that 
 of Stubbins Ffirth (35). He held that the experiences of Hew York, Baltimore, 
 and Philadelphia in the recent yellow-fever epidemics had shown that yellow or 
 malignant fever is not taken from the sick by physicians, nurses, and other 
 attendants. He mentioned instances in which persons, including himself, had 
 slept in the beds of yellow-fever patients without contracting the disease. In 
 his experiments on cats and dogs he was unable to reproduce the disease by 
 feeding black vomit to them. Black vomit introduced into the wounds on the 
 backs of dogs produced no ill effects, and in experiments on himself, including 
 the inoculation of black vomit into his eye, into wounds on his arm, drinking 
 it repeatedly in two successive epidemics, inoculation of himself on or under 
 the skin with the blood serum, the saliva, the perspiration, and the urine of 
 yellow-fever patients in the height of the disease, and finally drinking con¬ 
 siderable quantities of the blood serum of yellow-fever patients, the disease was 
 not produced. As all of these experiments, both on animals and on himself, were 
 negative, he concluded that yellow fever is not a contagious disease. 
 
 Davidge’s publication of 1798 had no immediate effect on modifying the 
 quarantine regulations of the first health ordinance. Indeed, in 1801 and in 
 
 1807, they were made more specific and comprehensive by amendments. In 
 
 1808, however, the quarantine laws were entirely repealed. 
 
86 
 
 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 Meanwhile, Potter’s notable address on contagion had been published in 1817, 
 and the severe yellow-fever epidemic of 1819 had been experienced and fully 
 written up by Dr. David M. Reese (25), and others (36). In his address of 1817, 
 from which quotations have already been made, Potter reviewed in elaborate 
 manner the history of the ideas concerning contagion and infection, the develop¬ 
 ment of quarantine systems in general, the quarantine regulations of New York 
 and Philadelphia in particular, and the British quarantine system. He con¬ 
 cluded not only that yellow fever was not contagious and was of local origin, but 
 he held up the whole quarantine system as practiced in his day to the severest 
 ridicule. 
 
 In regard to plague, Potter held that the idea that this disease is carried by 
 simple contact is refuted by experience and by the natural history of the disease. 
 He held that at any rate, so far as quarantine is concerned, it was of little or no 
 importance in America,, for in the form described by foreign writers it had 
 never been seen on our continent, although our commercial intercourse had 
 extended to all the countries which had generated it. He affirmed that the 
 quarantine laws of no nation had ever arrested the progress of any disease 
 except small-pox, and even despotic military discipline had failed to check the 
 progress of the plague. 
 
 On the question of quarantine against yellow fever, Potter found himself 
 in agreement with President Jefferson, concerning whose position he said: 
 
 “ From the commencement of the late pestilential plague in the United States, Mr. 
 Jefferson manifested a lively interest and instituted analytical investigation of the 
 origin of yellow fever. After an elaborate research, he declared the disease not conta¬ 
 gious and therefore not imported. In his communication to Congress in 1804, on the 
 state of the Union, he marks an era in the history of our country as the first public 
 functionary in the world, who dared to think for himself on this momentous subject.” 
 
 Potter deeply resented the inclusion by the British government of yellow 
 fever among the contagious diseases to be quarantined on the advice of medical 
 men unacquainted with the disease. His position in regard to yellow fever was 
 further supported not only by his own observations and the experiments of 
 Ffirth, but by his confirming in experiments on himself the negative results 
 obtained by Ffirth. The extensive investigations in regard to the etiology of 
 yellow fever carried out in Baltimore during the epidemic of 1819, as reported 
 by Reese and as recorded in the collection of Extracts from a Series of Letters 
 and other Documents, Relating to the Late Epidemic or Yellow Fever (36), 
 confirmed the opinion so forcibly expressed by Davidge and by Potter that 
 yellow fever in Baltimore was of local origin and not a contagious disease. 
 
 It is to be emphasized that the views in regard to the nature of the cause 
 of yellow fever were based not upon the opinions of any one man, but upon 
 the observations of a number of keen observers and close reasoners among the 
 medical profession of Baltimore. There had been ample opportunities for these 
 observations, for yell®w fever was present in the city in distinctly recognized 
 epidemics in 1794, 1797, 1798, 1799, 1800, 1802, 1819, and 1821. It was also 
 probably present in some at least of the intervening years and almost certainly 
 in 1807. During this time there is but one recorded observation of the intro¬ 
 duction of a case of yellow fever from the outside. This case was recorded by 
 Davidge (33), as occurring in August 1797, in a lady who had recently come 
 from Philadelphia, “ who brought with her the seeds of the disease,” and who 
 
PUBLIC HEALTH ADMINISTRATION OF BALTIMORE 
 
 87 
 
 was severely attacked with the disease while walking on Charles Street. She 
 had the genuine black vomit for two nights and a day. No person in her 
 family or in her neighborhood developed the disease. It was acknowledged by 
 Reese that in 1819 a few cases occurred on ships anchored off Fell’s Point, but 
 it was claimed that those people had been ashore, and it was denied that they had 
 the disease when the ships arrived. 
 
 Yellow fever almost invariably began at Fell’s Point, usually at or near the 
 particular locality of Smith’s Dock. The docks or slips between the wharves 
 at Fell’s Point were described as being filthy, containing a large amount of 
 decaying vegetable material which only moved out under the influence of strong 
 northwest winds. Just east of Fell’s Point there were large ponds filled with 
 stagnant water, and this part of the city is described as being ill paved, with 
 numerous collections of stagnant water, and abounding in every other variety 
 of nuisance. It was claimed by Potter (23), that no case of yellow fever ever 
 originated in West Baltimore above Hanover Street, beyond the sphere of 
 exhalation from the docks, wharves, and low grounds. The winds exerted a 
 definite influence upon the progress of the spread of the disease, it being 
 recorded by Davidge and Potter that in the epidemic of 1797, following a 
 strong east wind (northeast according to Davidge and southwest according to 
 Potter), the disease spread rapidly among the inhabitants of the upper part 
 of Frederick, Gay, South, and Calvert Streets and even to the vicinity of 
 Federal Hill on the other side of the basin. Potter noted in 1800 that the 
 increment of cases could be calculated with tolerable accuracy by observing the 
 variations of the winds. Reese, in his history of the epidemic of 1819 which 
 began at Smith’s Dock, Fell’s Point, attributed the spread of the disease from its 
 first circumscribed limits to the strong easterly wind which lasted for several 
 days. Shortly after a day of fasting and prayer, instituted by the mayor on peti¬ 
 tion of the clergy, the wind veered suddenly from the southeast to the northwest, 
 “ and blew with such force from that quarter that the basin was thoroughly 
 washed out, a general cleansing of the filthy situation of the docks was the 
 result, and the evidences, which had been previously offered that the disease 
 was progressing towards the healthier districts of the city, ceased to be ex¬ 
 hibited.” In this connection, it should be stated that Reese records that in this 
 year, yellow fever appeared at the same date at both the lazaretto and at Fell’s 
 Point. The lazaretto was some 2 miles to the east and south of Smith’s Dock 
 at Fell’s Point, and between them were the large filthy ponds previously alluded 
 to. At or near the same time that the disease appeared at the lazaretto and at 
 Fell’s Point, it prevailed also at Fort McHenry, immediately opposite the 
 lazaretto. In the light of our present knowledge, it is almost certain that the 
 disease was commonly introduced by shipping either at the lazaretto, where 
 ships first entered and were detained, or at Fell’s Point, where they unloaded 
 after passing the quarantine. A southeasterly wind tended to blow mosquitoes 
 from the lazaretto and its neighborhood to Fell’s Point and from the Fell’s Point 
 district to the lower portion of the city about the basin. A more easterly wind 
 passed over the lazaretto to Fort McHenry at the end of Whetstone Point. 
 A northwest wind would blow mosquitoes away from the city towards Fell’s 
 Point and from Fell’s Point towards the lazaretto and over Whetstone Point to 
 the Patapsco River. 
 
88 
 
 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 It was recorded by a number of observers, but with particular emphasis by 
 Potter and Reese, that the only individuals residing in the higher parts of the 
 city who developed yellow fever in these various epidemics were those who 
 visited infected districts, usually Fell’s Point, at night. Davidge, however, 
 records that a considerable number of persons from the higher parts of town 
 who went to Fell’s Point to witness the launching of a frigate contracted yellow 
 fever during the epidemic of 1797. It was emphasized in all records that no 
 one developed yellow fever after contact with cases outside of the yellow-fever 
 afflicted districts of the city. Davidge distinctly stated that from none of those 
 persons living up town who contracted the disease at the launching of the frigate 
 did the disease spread. Potter stated that in not a single instance was the disease 
 communicated to their associates by those persons who, living in the higher 
 parts of the city, contracted the disease after visits to the lower portions of 
 the city. 
 
 During these epidemics, but particularly in that of 1819, great numbers of 
 people from the infected districts were removed to the higher portions of the 
 city or to the surrounding country. Dr. Allender and Dr. Clendinen (36), 
 are recorded as saying that “ those who were seized with the disease and removed 
 did not propagate it, nor was anyone infected from the atmosphere by those 
 who imbibed the poison at its sourse.” In 1819, great numbers of yellow-fever 
 patients were removed from Fell’s Point to the hospital situated in the high 
 portion of the city on Broadway and Monument Street, and it was affirmed by 
 Reese that not a single case of the disease occurred among physicians, nurses, 
 or visitors to the hospital. 
 
 Reese was a strong adherent to the doctrine of the indigenous origin of 
 yellow fever and was thoroughly convinced that the disease was not contagious. 
 He was, therefore, an emphatic opponent of the usual quarantine system and 
 condemned the British physicians who advised their Government that yellow 
 fever was highly contagious, although a case of the disease had never occurred 
 on the island. While recognizing that the local quarantine laws were so amelio¬ 
 rated that Baltimore did not suffer half the inconvenience and delays of other 
 places, still he regarded the Baltimore practices as grossly absurd. He pro¬ 
 posed the following principles of quarantine: 
 
 “ If a vessel arrive from a foreign port, where it is known that at the time of her 
 departure the disease raged with unimpeded violence, let this vessel be examined by 
 the health officer; the sick, if any, removed; and if necessary the vessel be cleansed and 
 then suffered to proceed to her destination. This could all be done in forty-eight hours. 
 If, on the contrary, the vessel should be found to contain any vegetables in a state of 
 putrefaction, or if persons had been diseased and died on the passage after the vessel 
 was out at sea, then some detention should take place; but the healthy individuals on 
 board ought to be permitted to proceed to their place of destination. This kind of 
 quarantine would be consistent with the facts, and would prevent the importation of 
 any contagious disease more effectually than the one at present in vogue.” 
 
 For another reason he protested against quarantine regulations. He held that 
 the practice of detaining vessels at a lazaretto 12 to 40 days, in the heat of 
 summer, without any cleansing or ventilation, was calculated to effect what it 
 was intended to prevent. If such vessels thus proscribed contained coffee and 
 other substances liable to undergo putrefaction, they would at least be injured 
 by the detention, and if they were damaged at all, the lack of ventilation would 
 increase the damage. 
 
PUBLIC HEALTH ADMINISTRATION OF BALTIMORE 
 
 89 
 
 “ Such vessels are then permitted to proceed to the center of our cities, the hatches 
 are removed, and the gas evolved from their holds is so fetid and poisonous that whole 
 cities are infected by the noxious vapor generated during the detention of the vessel; 
 and if she had been suffered to come up to unload at once upon her arrival, no mischief 
 would have resulted, but much evil would have been avoided.” 
 
 He deprecated copying European authorities either in politics or science. 
 
 In connection with the idea of the indigenous origin of yellow fever, Potter 
 stated that when, in consequence of the embargo on foreign commerce in 
 1807, no foreign sail appeared in the Baltimore Harbor, yellow fever broke out 
 at Fell’s Point. 
 
 These ideas were supported by the opinion of the organized profession in a. 
 letter (36) signed by Dr. Ashton Alexander and Dr. John B. Caldwell, secre¬ 
 tary of the District Medical Society, written in reply to a letter of David 
 Burke, chairman of the committee of the city council in charge of the health 
 ordinances, who had propounded seven questions concerning the causes of yellow 
 fever and its relation to local conditions. In the letter referred to, Dr. Alex¬ 
 ander and Dr. Caldwell, after describing the general sanitary conditions of 
 Fell’s Point, stated definitely that, in the opinion of the society, the yellow 
 fever of 1819 was to be ascribed to the decomposition of vegetable matters 
 about the wharves, in the streets, the ponds, and cellars. They explicitly stated 
 that the society did not consider the putrefaction of animal matters competent 
 to the production of yellow fever, and that “ the doctrines of contagion and 
 importation received no countenance from this society.” They expressed belief 
 that the cause of the disease may be imported, if by this is understood a cargo 
 of vegetable substances in a putrescent state. They had observed no differences 
 in the habits and modes of living of the people in the infected district from 
 those of the people of the same rank living in parts of the city where the disease 
 did not prevail. In regard to the organization of the board of health, they gave 
 it as the opinion of the society that it should have at least one medical member 
 with whom to hold counsel and to whom they might refer on points touching 
 the health of the city. They recommended that the quarantine regulations 
 should be strictly enforced in all cases where the cargoes were damaged or the 
 vessel in a foul state, until a change of conditions would safely permit her 
 entrance into the port, but this recommendation was not intended to deprive the 
 passengers or crew of the privilege of free communication with the city. 
 
 These recommendations ended in a complete recasting of the health depart¬ 
 ment, and the new health ordinance of February 29, 1820, framed after the last 
 great yellow-fever epidemic, under the influence of the Medical Faculty and 
 under the mayoralty of Dr. Edward Johnson, a leading physician, contained 
 no quarantine provisions. 
 
 In the light of the foregoing, it is well rapidly to review the correlation 
 between these ideas and the quarantine regulations and practices of Baltimore. 
 From the above facts, quoted from contemporary literature, and from a con¬ 
 sideration of the health ordinances, it is clear that the early quarantine regula¬ 
 tions and practices were determined by the ideas held concerning the etiology 
 and mode of transmission of yellow fever. The ordinances of 1797 provided a 
 10-day quarantine on ships and their personnel, arriving from beyond the seas 
 and “ all other suspected places,” only during the months between April 1 and 
 October 1 (the yellow-fever season), and gave the health authorities power to 
 
90 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 interdict the landing of damaged coffee, hides, or other damaged material— 
 substances from which it was believed the cause of yellow fever might arise. 
 
 Four years later, in 1801, the quarantine restrictions were limited to vessels 
 from both the Indies, Africa, South America, the Mediterranean, and connected 
 waters east of Gibraltar, and the ports of the western coast of Spain, as far as 
 Cape St. Vincent, but only between May 1 and November 1. The primary 
 quarantine period was 3 days, with extension by an additional 10 days, at the 
 discretion of the quarantine officer. Vessels from such ports were, however, 
 required to discharge cargoes and ballast at the quarantine station, and 
 ventilation of the ship and wearing apparel of persons on board was enforced. 
 Vessels loaded with coffee (from West Indian or other ports), arriving between 
 June 1 and October 1, could discharge cargoes into lighters instead of at the 
 quarantine station. Under both ordinances, the sick on vessels were sent to 
 the hospital at Hawkins’ Point. The restriction of the quarantine season to 
 the four or five hot months, the short duration of detention, and the mildness 
 of the regulations in regard to ships, goods, clothing, and persons, and the total 
 abandonment of all quarantine regulations between 1808 and 1821 prove that 
 the quarantine system was directed against yellow fever especially, rather than 
 against plague, small-pox, typhus fever, or other diseases. It is to be noted that 
 when the health ordinances were entirely recast in 1820, when by common 
 consent yellow fever was regarded as of local origin and not contagious, all 
 provisions for quarantine of the port were omitted. The very liberal quarantine 
 laws revived in 1821 and expanded in 1823, while still stressing the impor¬ 
 tance of materials, provided for the examination of persons and prepared the 
 way for the more stringent investigation of persons, both crew and passengers, 
 made mandatory in the revised health ordinance of 1826. The latter and 
 various successive ordinances left general details of the quarantine system to 
 the quarantine officer and the board of health. By 1826, the tide of immigra¬ 
 tion to Baltimore from Europe, which had set in after the close of the 
 Napoleonic wars, had reached a high point, and it was to protect the city 
 against small-pox and typhus fever likely to be brought in by these immigrants 
 that the quarantine system was revived in its new form. So far as yellow fever 
 is concerned, the Baltimore authorities prided themselves that they never 
 instituted quarantine against any port on account of that disease, and they 
 sharply criticized Alexandria, Virginia, for imposing quarantine restrictions 
 upon Baltimore for that reason. During the severe epidemics of this disease 
 at Norfolk, Portsmouth, and Gosport, Virginia, in 1855, Baltimore kept up 
 active trade with her stricken sisters, and welcomed their refugees in large 
 numbers. So convinced were the Baltimore authorities of the unwisdom of a 
 stringent quarantine system that, in 1830, Dr. Horatio G. Jameson, the con¬ 
 sulting physician of the health department, went to an international meeting 
 of hygienists in Hamburg with the purpose of inducing continental authorities 
 to modify their quarantine regulations to conform with those of Baltimore. 
 In 1832, when an invasion of cholera was imminent, Dr. Jameson held that this 
 disease is not contagious and that restrictive measures should not be attempted. 
 Though the mayor agreed with him, on account of opposition on the part of 
 the council and the public, they were unable to act consistently with this 
 doctrine. 
 
PUBLIC HEALTH ADMINISTRATION OF BALTIMORE 
 
 91 
 
 On account of the lack of the reports of the health officer or quarantine 
 physician before 1827, it is not possible to review with any accuracy adminis¬ 
 trative practices of this official under the quarantine laws before this date. 
 It is probably correct to assume that he carried out the spirit, if not the letter 
 of the ordinances which obtained. It will be recalled that by the ordinances 
 of 1823 and of 1826, the quarantine was reestablished with the retention of 
 the better features of the old laws, and that by the late ordinances the health 
 officer, under the commission of health, was to determine whether and to what 
 degree quarantine should be imposed on coastwise and foreign vessels. 
 
 All vessels were required to anchor at the quarantine-ground for examination 
 of the passengers, crew, and cargo. The health officer passed them at his 
 discretion. Vessels that he held for quarantine were sent to the lazaretto for 
 cleaning and for the discharge of cargoes and passengers. Private vessels and 
 vessels with more than 15 passengers, arriving from sea were required to land 
 their ballast and empty and cleanse their water casks at the lazaretto wharf. 
 Their timbers were inspected by the health officer before the vessels were per¬ 
 mitted to come to any wharf within the limits of the city. 
 
 As a matter of practice, as shown by the annual reports of the quarantine 
 officer since 1827, it had been the custom to retain at quarantine cases of yellow 
 fever, cholera, small-pox, typhus fever, and occasionally scarlet fever, measles, 
 and malarial fever from incoming ships, and in case of small-pox on board to 
 vaccinate everyone, both crew and passengers, and to pass the ship after dis¬ 
 infection. The methods of disinfection included removal of the whole cargo 
 and airing it at the Lazaretto, cleaning and washing the ship, and the use of 
 various disinfectants. 
 
 As an indication of the amount of work entailed during the quarantine 
 period of 1827, there were 546 ships, of which 177 were from foreign ports and 
 carried 1,429, out of a total of 1,688 passengers. In 1829, 4,600 passengers 
 were inspected by the health officer. From 1827 to 1834 it was recorded that 
 the health officer examined 44,821 passengers, of whom 40,973 were foreigners. 
 
 The clothing of those sick with small-pox, or typhus or yellow fever, was 
 usually sunk or burned, but, for a while at least, it was passed after being 
 well aired. 
 
 The health officer made frequent comments upon the condition of immigrant 
 passengers. In 1829, he states that the passage money of many of the immi¬ 
 grants was provided by the parish from which they came. He often remarked 
 upon the destitute and filthy condition of the immigrants and upon their cor¬ 
 poreal and mental disabilities, which caused the assignment of many of them 
 to the Baltimore almshouse. In 1837 he estimated “ that 75 per cent of the 
 immigrants included the halt, lame, blind, mendicants, and persons unac¬ 
 quainted with any kind of business except laboring.” Many of the immigrants 
 at this time were Irish and German. 
 
 Ships from infected ports were passed if the personnel was healthy, the 
 ships clean, and the cargoes without damaged goods. “ Damaged goods ” were 
 those that showed evidences of spoiling and putrefaction, chiefly coffee and 
 hides, and they were aired at the lazaretto before being brought to the city. 
 Until the goods were submitted to this process for an uncertain period they 
 were not allowed to be brought to the city. The health officers were greatly 
 
 4 
 
92 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 exercised over the foul condition of the holds of vessels and apparently had 
 more trouble with coastwise than with foreign vessels on this account. In 
 1829, Dr. Samuel B. Martin, the health officer, reported much benefit in 
 cleaning the holds of vessels from the use of “ chlorine in combination with 
 lime.” This is the only mention made of the use of a particular disinfectant, 
 but it is probable that lime was most commonly used for this purpose. 
 
 These practices were enforced with little modification until 1847. The 
 reports of the health officers during this period indicate that careful examina¬ 
 tions of crew and passengers were carried out routinely, particularly for small¬ 
 pox, typhus fever, and yellow fever, as well as for cholera during epidemics of 
 that disease. One of the practices early established was that of vaccinating 
 both passengers and crew when a ship was held for either small-pox or typhus 
 fever. No indication is given as to how long ships with infected passengers were 
 held or for how long a period well persons on infected ships were quarantined. 
 The sick were removed at once to whatever hospital accommodations were 
 available. 
 
 It does not appear from the records when removal and airing of cargoes and 
 the cleansing of vessels were stopped. The abandonment of these practices 
 apparently coincided with the adoption of uniform quarantine plans for all 
 ports, under the general direction and with the co-operation of the United 
 States Marine Hospital Service and its successor, the United States Health 
 Service after 1880. 
 
 Throughout the history of the quarantine service, both before and after its 
 modifications to conform in a general way with the restrictions and methods 
 advocated by the Federal Government through the Marine Hospital and 
 Public Health Services, it has been the practice of the health department to 
 hold at the quarantine station discovered cases of small-pox, typhus fever, 
 yellow fever, cholera, and severe cases of malaria. 
 
 THE LAZARETTO AND HOSPITAL FACILITIES IN CON¬ 
 NECTION WITH THE QUARANTINE PORT. 
 
 Baltimore City inherited from Baltimore Town a small quarantine hospital, 
 the construction of which had been authorized by the legislature at the time 
 of the yellow-fever epidemic in 1794. It was situated at Hawkins 5 Point, on 
 the southern shore of the Patapsco, due west across the river from Sparrow’s 
 Point and Fort Carroll, about 4.5 miles due south from Fort McHenry, and 
 about 3.5 miles southwest from the Lazaretto Light. It was probably reached 
 only by boat. There is no record of the number of patients with yellow fever 
 or other diseases that were accommodated there. It was completely under the 
 jurisdiction of the Baltimore Health Department and was probably in use 
 until 1830. In that year arrangements were made with the Director of the 
 United States Marine Hospital Service in Baltimore to have the most com¬ 
 fortable part of the lazaretto fitted up with plain accommodations for the 
 reception of cases of contagious diseases arriving on ships. The lazaretto for 
 the reception, airing, and cleansing of goods taken from ships was owned by the 
 United States Government and was established shortly after 1801 at Lazaretto 
 Point, about 2 miles southeast of Fell’s Point, just across the river from 
 Fort McHenry, and at the junction of the southern and eastern boundary lines 
 
PUBLIC HEALTH ADMINISTRATION OF BALTIMORE 
 
 93 
 
 of the city as they existed from 1816 to 1919. It is probable that the health 
 officer boarded ships from the lazaretto until 180?, when his office was estab¬ 
 lished at Fort McHenry. The lazaretto was a large quadrangular building, but 
 there are no plans extant, giving the size and plan of the lazaretto buildings 
 and wharves. 
 
 The first lazaretto was destroyed by fire in 1836. The Marine Hospital 
 Service apparently had no hospital for sailors sick with ordinary diseases until 
 recent years. For many years, at least, they were evidently sent to different 
 hospitals in the city. 
 
 About 1845 there was constructed by the city a new quarantine station of 
 considerable size, called the Marine Hospital. It was situated at what is now 
 known as Fairfield, on the southern shore of the Patapsco River, about 1.25 
 miles directly south of Fort McHenry. This hospital, while designed primarily 
 to accommodate sick immigrants, was provided with additional accommodations 
 to be used as a pest-house chiefly for cases of small-pox and typhus fever from 
 the city. It is evident that the accommodations at the pest-house were at times 
 insufficient to accommodate all the cases of typhus fever taken from vessels at 
 quarantine, for Thomas H. Buckler records that in 1847 some of the first cases 
 of typhus fever brought by the ship Rio Grande were sent to the medical wards 
 of the Baltimore City and County almshouse and that with the repeated arrival 
 of immigrant ships with cases of the disease, these wards were filled with 
 typhus cases in the course of a few weeks. The name, Marine Hospital, was a 
 misnomer, for it was not a hospital for mariners, but for immigrants, as well 
 as a pest hospital for the city. It is probable that, at times at least, sailors with 
 communicable diseases were received there. For some years this hospital was 
 under the charge of a resident physician, but later the health officer or quaran¬ 
 tine officer was given charge of it. 
 
 It appears that during the Civil War the United States Government erected 
 a flimsy barrack hospital on these grounds, and after the war this structure 
 was taken over by the city as a pest hospital. 
 
 In 1881, the quarantine station was moved to Leading Point, about 8 miles 
 below Fort McHenry. Here two wooden structures were erected, one for sailors 
 and passengers with contagious diseases and the other, a large, barrack-like 
 structure, as a pest-house for the city. In connection with the hospital there is 
 a large steam disinfecting plant. 
 
 Both the old Marine Hospital and the quarantine station at Leading Point 
 were best reached from the city by water. The road to the former was always 
 excreable and that to the latter, until recently, was rough. 
 
 THE EFFECTIVENESS OF MARITIME QUARANTINE. 
 
 As will appear very clearly in the separate studies of the course of various 
 epidemic diseases, the quarantine station of the Port of Baltimore did not, 
 until very recent years, at least, offer a very efficient barrier to the ingress of 
 certain diseases, epidemic waves of which have repeatedly broken over the city. 
 
 In nearly every year between 1794 and 1807, the period of most stringent 
 quarantine laws, there were larger or smaller epidemics of yellow fever. In 
 the latter year, owing to an embargo on shipping, no foreign vessels entered 
 the port. In 1793 there was a large immigration from San Domingo, but no 
 
94 
 
 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 cases of yellow fever were recognized in the city. These immigrants arrived at 
 the time when the local quarantine was under the State officials. Within the 
 next 20 years, partly on account of this immigration, there was a great increase 
 in trade with the West Indies, and particularly with San Domingo. Although 
 between 1807 and 1821 there were no quarantine laws in force, yellow fever 
 was recorded in Baltimore only in 1819 and 1821. From 1812 to the spring of 
 1815, shipping was to some degree interferred with on account of the war. 
 
 The reports of the quarantine officer are available from 1827. These contain 
 no records of the detention of cases of yellow fever until 1848, when there was 
 1 case. Between 1848 and 1900, a period of 52 years, there were removed from 
 vessels a total of 83 cases of yellow fever, 28 of which were detained in the 5- 
 year period 1855-1859. The largest number of cases detained in a single year 
 was 12, in 1855; 10 cases were detained in 1870; 6 cases in 1857 and 1884; 5 
 cases in 1859, 1873, and 1877; 4 cases in 1856, 1874, and 1894; 3 cases in 
 1891; and 2 cases in 1849, 1853, 1872, 1875, 1879, and 1897. In nine other 
 years there were single cases. In 1853, when 2 cases were detained at quaran¬ 
 tine, there were 18 fatal cases in the city, and in 1859, when 5 cases were taken 
 from vessels, 5 cases occurred within the city. It is of special interest that in 
 1855, with 12 cases at quarantine, there were 13 deaths from the disease in 
 the city, occurring among refugees from the cities at the mouth of the Chesa¬ 
 peake Bay, but from none of these cases did secondary cases arise. Cases of 
 the disease were detained each year at quarantine from 1872 to 1881, inclusive. 
 It is not known, of course, how many cases occurred within the city among 
 individuals passed at quarantine. 
 
 After 1831 there was a drop in the West Indian trade, but a gradual increase 
 in shipping from South American ports. 
 
 Though it is certain that typhus, jail, or ship fever was early included among 
 the “ pestilential diseases ” by the local health department, the records of the 
 quarantine officer made no mention of detained cases of this disease before 1845. 
 The tables of interments, however, show that deaths from typhus fever occurred 
 in the city every year from as early as 1813 at least until 1861, and that this 
 disease was the cause of a considerable number of deaths in 1814-1815, 1818- 
 1820, 1823-1824, and 1847-1850. (See Table 17.) Since cases of typhus fever 
 and small-pox, originating within the city, had been sent to the marine or 
 quarantine hospital by 1845, it is impossible to determine what proportion of 
 the cases recorded at the station were taken from ships. However, during the 
 time of the great Irish immigration beginning in 1847, a considerable number 
 of cases were recorded at the quarantine hospital: 101 in 1847, 14 in 1848, 
 140 in 1849, 6 (all said to have come from the city) in 1850, 10 in 1851, 54 in 
 1852, 30 in 1853, 23 in 1854, and 6 in 1855. Only 3 cases of typhus fever were 
 recorded between 1857 and 1869: 2 in 1857 and 1 in 1866. In 1870 there 
 were 282 cases, and in 1871, 17, probably most of them from the city. Since 
 this date there have been a few cases recorded in occasional years. 
 
 In only a few years between 1850 and 1919 were there no cases of small-pox 
 recorded at the quarantine station or its hospital. However, as from the earliest 
 times cases of this disease were sent from the city to whatever hospital existed 
 in connection with the station, it is not possible to estimate what proportion 
 of the recorded cases represent cases removed from vessels. In the older reports, 
 
PUBLIC HEALTH ADMINISTRATION OF BALTIMORE 
 
 95 
 
 from 1827 to 1847, specific mention is made of removal of cases from vessels, 
 as, for instance, 2 cases in 1827, 1828, and 1831, respectively, “ several 
 cases ” in other years, 16 cases in 1836, and 30 cases in 1837. Often the name 
 and nationality of the vessel, usually German from Bremen, is given. After 
 1845, when a ward of 20 beds was provided for small-pox patients at the 
 Marine Hospital, considerable numbers of cases are known to have been sent 
 from the city, and in some years the number of such cases is given. These 
 years mark the known epidemic years of small-pox in the city. In some of 
 these years the cases numbered hundreds. 
 
 Cases of cholera are recorded as having been removed from vessels only 
 twice, once each in 1850 and 1866. Cases of cholera were looked for by the 
 quarantine officer in 1832, the great cholera year, but none were discovered on 
 ships entering the port. 
 
 After 1847, malaria, typhoid fever, and occasionally scarlet fever and measles 
 are mentioned. Though not stated in the reports, it is a well-attested fact 
 that the authorities permitted large steamship companies to enter into contracts 
 with general hospitals in the city to receive cases of scarlet fever, measles, and 
 diphtheria from their vessels, and that there was a competition between at least 
 three such hospitals for these contracts. The city's hospital facilities at quar¬ 
 antine were, and are yet, hopelessly inadequate to accommodate more than a 
 few such cases. Indeed, until very recently, no attempt was ever made to pre¬ 
 vent the importation of cases of these diseases directly into the city. Before 
 1850 they were not regarded as “ pestilential diseases.” As late as 1893 it was 
 not unusual for one of these general hospitals to receive as many as a hundred 
 cases of measles from a single North German Lloyd immigrant steamer. 
 
 In regard to typhus and typhoid fevers, small-pox, measles, scarlatina, diph¬ 
 theria, influenza, and probably cholera, the dispassionate student is forced to 
 the conclusion that the quarantine system, as applied at the port of Baltimore 
 and at other Atlantic seaports, until recently was futile. In 1851, Thomas H. 
 Buckler (11) pointed out that in 1847 typhus fever was diffused throughout the 
 city by Irish immigrants who were passed by the quarantine authorities, and 
 he severely criticized the quarantine facilities and methods of the port as 
 inadequate. Many, if not most, of the severe European epidemics of these 
 diseases have been reflected in Baltimore. No quarantine system has kept 
 them out of some port, and, having visited the country, they have spread to 
 Baltimore through her otherwise open portals if not through the only partly 
 closed door of the quarantine station. That at times a few cases of one or 
 another of these diseases have been kept from entering by this portal may be 
 assumed. 
 
 It is very probable that since 1845 the maritime quarantine has served a 
 good purpose in preventing the ingress of cases of the severer types of malarial 
 fever from Central and South America. This is counterbalanced, however, 
 by the fact, attested by the quarantine physicians, that many patients with 
 small-pox and typhus fever sent from the city to the old Marine Hospital died 
 of malarial fevers contracted there. 
 
 A fair evaluation, at this late date, of the efficacy of the quarantine in pre¬ 
 venting epidemics of yellow fever in Baltimore is almost impossible. The facts 
 must be faced that during the early years of most active quarantine the disease 
 was prevalent in epidemic form nearly every year; that when the quarantine 
 
96 
 
 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 was done away with, it occurred but twice in 16 years; that after the quaran¬ 
 tine was reestablished in 1821, though cases of the disease are known to 
 have existed in the city on several occasions, it has never spread generally; and 
 that moreover, in some years when no cases were detained at quarantine, the 
 disease broke out in the city, as, for instance, in 1854, when over 40 cases 
 occurred at Fell’s Point. Stegomyia mosquitoes, which must have been present 
 in the lower parts of the city as late as 1821, could hardly have been done away 
 with by the unconscious and incomplete anti-mosquito work of that date. 
 The most reasonable explanation is that quite fortuitously those yellow-fever 
 patients who did get into the city, in 1855 for instance, did not go to the lower 
 portions of the city at Fell’s Point and the basin near Jones Falls. It is more 
 than likely that, until late years, chance, rather than art, has controlled this 
 situation. 
 
 In regard to bubonic plague, little need be said, for history shows that this 
 disease has never been, at least not until recently, a menace at Atlantic ports, 
 any more than at British ports during the same period. Until the last part of 
 the nineteenth century the disease had not migrated to Europe or to America 
 for centuries, and since that time it would appear that when it approached a 
 port it has often entered despite quarantine. Even when it has gained admis¬ 
 sion and has spread widely among rodents, as in San Francisco and New 
 Orleans, the disease has never attacked man in grave epidemic form. It seems 
 that the immunity of western Europe and of America to deadly epidemic plague 
 since the seventeenth century is to be explained by the natural history of the 
 disease rather than by man’s precautionary efforts. No one who is familiar 
 with what is known of the natural history of this disease can entertain the 
 idea that the quarantine system of Baltimore, at least before 1900, could have 
 possibly afforded any protection against its invasion. 
 
Chapter VI.—Public Health Administration 
 
 within the City. 
 
 I. Introduction: Developments and accomplishments of public health 
 practice in the nineteenth century, based upon ideas and methods long 
 existent and determined very largely by the more general diffusion of 
 knowledge and wealth among peoples of intellectual and personal freedom; 
 Influence of modern micro-parasitology; Reasons for vigorous attacks on 
 nuisances rather than on contactive diseases. 
 
 II. Measures of nuisance prevention and abatement directed against 
 nuisance-borne diseases: Definition of nuisance; Prevention and abate¬ 
 ment of nuisances on public property—Dredging and filling; Grading and 
 paving; Street cleaning and garbage removal; Sewerage; Water; Food; 
 Prevention and abatement of nuisances on private property—Standing 
 water; Organic matter; Manufactories; Habitations. 
 
 III. Measures of restriction directed against contagious diseases: 
 Isolation, inoculation and disinfection. (Tables 4 to 6.) 
 
 INTRODUCTION. 
 
 It is customary to date the beginning of modern public-health administra¬ 
 tion and practice in municipalities from about the middle of the nineteenth 
 century and to attribute the general sanitary reforms which were actively 
 undertaken at this time in certain European and American cities to newly 
 acquired knowledge. And especially is it the habit to ascribe to advancing 
 knowledge in micro-parasitology the more vigorous efforts to control disease 
 by measures of general sanitation and of personal control which have been 
 made during the past 40 or 50 years. It is, however, a great mistake to suppose 
 that these activities had their origin directly in any very essentially new knowl¬ 
 edge discovered by the generation by which they were undertaken. The final 
 establishment upon a firm basis of the ancient germ theory of the causation of 
 the febrile diseases did not in principle add nearly so much to the methods 
 available for preventing the spread of these diseases through communities or 
 from place to place as those ignorant of history have assumed to be the case. 
 While the newly acquired knowledge changed reasons assigned for the employ¬ 
 ment of certain measures, it did not modify methods of practice in any very 
 fundamental manner. Tactics rather than strategy were modified, but neither 
 was greatly enriched, so far as the typically contactive diseases are concerned, 
 to a degree that can be called revolutionary. It is so widely believed and taught 
 that the decrease in incidence and in mortality of so many of the acute and 
 chronic febrile diseases in western civilization has been due solely to the appli¬ 
 cation of new methods of sanitation and of personal control based upon the 
 wonderful advances in our knowledge of micro-parasitology within the past 
 50 years, that it is well at this point to submit this claim to critical analysis. 
 
 In the first place, the beneficial influence of an abundance of pure water 
 for drinking and bathing, of surface and sanitary sewerage, of sanitary latrines 
 for the disposal of human dejecta, and of well-paved and well-cleaned streets 
 upon the public health and comfort was well-known to the ancients. The 
 
 97 
 
98 
 
 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 Romans, especially, brought these measures to a high degree of perfection, 
 and their practices in these respects became well known to students, at least, 
 with the revival of the study of classical literature during and after the 
 Renaissance. The Romans set up a health department, effectual so far as 
 matters of general sanitation are concerned, under the administrative charge 
 of the agdiles, with district physicians who attended the poor and were on the 
 outlook for epidemic diseases. A similar system was revived in certain Italian 
 cities, notably Venice, in the fifteenth century. According to Manzoni (37), 
 before the plague epidemic of 1630 Milan had a permanently organized board 
 of health, with physicians among its members and with lazarettos for the 
 isolation of the sick. It will be recalled that the quarantine system of the 
 Mediterranean ports was elaborately organized in the seventeenth and eighteenth 
 centuries. On Mead’s advice this system was copied in England for emergencies 
 in 1720. Mead’s (14) “ recommendations ” for the control of the spread of 
 the plague in England embodied all the essential principles of restriction of 
 contactive diseases by measures directed to the control of persons and their 
 immediate contactive environments in use at the present day. The fundamental 
 importance of Mead’s recommendations is evident from the following synopsis: 
 
 1. Local health councils with physicians and magistrates among the members 
 should be established and exercise full authority. 
 
 2. Physicians should be employed to search out cases and a reward offered to the 
 person reporting the first case in a community. 
 
 3. When cases of the disease are found in households or elsewhere, the sick should 
 be separated from the sound, by removing the former, preferably at night, to 
 clean and airy habitations 3 or 4 miles out of town (hospitalization), and given 
 every care and attention. 
 
 4. The sound in such households should be well washed and shaved and given 
 fresh clothes before removal to lazarettos for observation. The clothes previously 
 worn should be burned or buried. 
 
 5. All the goods within houses from which the sick are taken should be buried. 
 The houses should be either demolished, or else thoroughly cleaned and replastered, 
 and fumigated with vinegar or sulphur. 
 
 6. The bodies of the dead should be buried deeply. 
 
 7. Those attendant upon the sick, while near the latter, should not draw in their 
 breath nor swallow their saliva, but should frequently wash the mouth and nose 
 with a solution of vinegar. 
 
 8. Healthy inhabitants who could afford it should be allowed to leave the town, 
 after undergoing a period of detention in isolated detention camps for 20 days. 
 
 9. Assemblages of people should not be allowed, and beggars and idlers should 
 be confined. 
 
 10. Proper authorities should see that the houses of the poor are kept clean 
 and sweet. Whenever an overcrowded condition is discovered, some of the dwellers 
 should be removed to other quarters. 
 
 11. Streets should be washed clean and kept free of carrion and other nuisances. 
 Laystalls should not be too near the city. 
 
 12. Lines should be cast about infected towns, and guards should prevent persons 
 from passing to other places until they have performed a quarantine of 20 days 
 under suitable precautions. All travelers should have certificates. No material 
 considered retentive of infection should be passed through the lines. 
 
 13. All the expenses incurred should be borne by the public. 
 
PUBLIC HEALTH ADMINISTRATION OF BALTIMORE 
 
 99 
 
 These measures against plague, advised by Mead, and evidently largely bor¬ 
 rowed from Italy, have been given the credit of checking the spread of the dis¬ 
 ease. They were applicable, and doubtless were applied, to other epidmic dis¬ 
 eases, and provision for such application, in part at least, to Baltimore was made 
 in the earliest health ordinances. In regard to the typically contagious diseases, 
 these regulations were equally applicable, whether it be held that these affec¬ 
 tions are caused by emanations of unorganized form from the bodies of the 
 sick, or by contagia viva, or micro-parasites. Whichever the true explanation 
 of their causation, separation of the sick from the well, avoidance of contact 
 with the sick and the articles of their contactive environment, the destruction 
 of these articles by fire or their purification by chemicals, ventilation, and 
 sunlight, have been and yet remain standard procedures. The necessity of early 
 notification of the occurrence of cases of disease in order that standard pre¬ 
 cautionary measures could be taken and of holding suspects during the period 
 of incubation was as evident in Mead’s day as in this. 
 
 Vaccination against small-pox has been available as a public-health measure 
 since 1798 and has been practiced in Baltimore since 1800, but, as elsewhere, 
 in a fashion quite inadequate. But the value of variola inoculata as a preventive 
 measure against variola vera or small-pox was announced in England by Lady 
 Mary Wortley Montagu, in 1716, and in 1744 the western world was informed 
 through Mead’s publication of an English translation of Rhazes’s classical 
 work on small-pox that the Chinese and other eastern peoples had for centuries 
 employed successfully variola inoculata as a substitution disease against 
 small-pox. Indeed, the great virtue of Jenner’s discovery lay in the fact that 
 vaccinia is a milder affection than variola inoculata and that its use avoids 
 keeping the small-pox virus alive in a community. 
 
 Almost from time immemorial, pulmonary tuberculosis, like leprosy, has 
 been held to be spread by intimate personal contact; yet the latter, during many 
 centuries, has been combated by segregation (and apparently with great success 
 in Europe), while restrictive measures against the former have come into vogue 
 only in recent years, and then on a very restricted scale. When the difference 
 in man’s conduct toward these two affections is considered, it seems likely that 
 his actions must have been governed more by vanity and horror than by reason. 
 It is doubtful if leprosy was ever, within historic times, endowed with a force 
 of morbidity and mortality of the same high degree as was pulmonary tuber¬ 
 culosis. The disease of lesser frequency is characterized, however, by visible 
 lesions leading to hideous deformities and superficial decay and attended by 
 feelings of despair, while with its more common and usually more rapidly 
 fatal sister the lesions are hidden, hope commonly persists to the end, and the 
 victim inspires sympathy rather than disgust. It is interesting to speculate 
 on what would have happened had the ancients applied segregation to the 
 pulmonary tuberculous with the same determination with which they exercised 
 it on the leprous. 
 
 It would appear that until the middle of the nineteenth century western 
 Europe and North America were stirred to activities of disease control only by 
 deadly epidemics, mainly those of diseases marked by horrible external char¬ 
 acters. Small-pox, disgusting to sight and smell and marked by facial defor¬ 
 mities and blemishes in the recovered, plague with its discoloration of the skin 
 
100 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 and its suppurating buboes, and the contagious ophthalmia of the East, dis¬ 
 figuring man’s best feature and commonly leaving a legacy of blindness, all 
 illustrate this point. Typhus fever, influenza, scarlet fever, measles, diph¬ 
 theria, whooping-cough, syphilis and gonorrhoea, and the less dangerous mumps 
 and varicella—diseases then and now commonly reckoned as contactively 
 spread—excited only occasionally administrative reactions of a protective 
 nature. Syphilis has excited popular dread only when its victims showed super¬ 
 ficial lesions with destruction of tissue and disgusting appearances and odors. 
 The same may be said of superficial tuberculosis or scrofula. Gonorrhoea is yet 
 regarded popularly as too mild a disease to call for the use of the obvious 
 measures to avoid it. 
 
 In Baltimore the early sanitary measures undertaken against diseases sup¬ 
 posedly caused by effluvia from the decaying of dead organic matter were 
 inspired as much by the fear of the dreaded yellow fever as by fear of the cus¬ 
 tomary, annual visitation of malarial diseases, to which a great proportion of 
 the deaths were attributed every year. 
 
 Against endemic affections of steady march and less spectacular lethal capaci¬ 
 ties, man commonly exhibited stolid indifference, fostered by familiarity, 
 superstition, and a feeling of helplessness. 
 
 The discovery since 1898 that malaria and yellow fever are carried by mos¬ 
 quitoes acting as intermediary hosts, and that typhus fever is spread from sick 
 to well by body-lice, was not essential for a considerable control over, if not 
 for the eradication of, these diseases, and, indeed, they all had shown marked 
 regression and had practically disappeared in many countries before this time. 
 In fact, it is not going to far to state that malaria and yellow fever had been 
 eliminated or in great degree curbed in many places, including Baltimore, 
 long before it was demonstrated that they are caused by micro-parasites and 
 under natural conditions, at least, transmitted only through the mediation of 
 certain species of mosquitoes. Measures directed against standing water, such 
 as draining and filling low grounds, making cellars dry, sealing cesspools, 
 planting trees, and the like, are, of course, of equal value in preventing mos¬ 
 quito breeding and the formation or the escape into the air of effluvia from 
 decaying organic matter. The avoidance of low grounds and of exposure to 
 the open air at night, precautions taken for empirical reasons, are efficacious 
 for escaping malaria and yellow fever, when prevalent, whether adopted under 
 the influence of the marsh miasma or the mosquito theory. The mosquito net 
 and the window screen were in general use long before the relation of these 
 insects to the spread of these fevers was discovered. Finally, the value of 
 routine doses of cinchona bark, or of its active principle, quinine, in warding 
 off malarial infection in malarious districts has long been recognized. This 
 practice was successfully employed in the eighteenth century in armies, in the 
 British navy, in the British settlements on the Guinea coast, and elsewhere. 
 During the nineteenth century, preventive doses of cinchona bark or of quinine 
 in whisky or brandy (as first used in the Imperial army on the Danube in 
 1717-1718) became a commonly practiced measure of personal hygiene in 
 Baltimore. According to Dr. W. T. Councilman, this prophylactic remedy was 
 furnished by the Baltimore health department as late as 1880 to the officials 
 and help at the quarantine station, which was situated in a severely malarious 
 
PUBLIC HEALTH ADMINISTRATION OF BALTIMORE 
 
 101 
 
 district. It was taken twice daily by the whole force, and hy one employee 
 in amounts sufficient to cause permanent deafness. Until very recent years it 
 was the fixed habit of physicians in Baltimore to pour quinine into patients 
 suffering with various diseases whenever a “ malarial complication ” was 
 suspected. As dysentery was believed to he an “ expression of malarial intoxi¬ 
 cation ” (and doubtless the two diseases often coexisted in the same individ¬ 
 ual), quinine, or “the bark/’ was commonly administered for this disease as 
 a matter of routine. It is a curious fact that until very recently health depart¬ 
 ments failed to advocate the use of prophylactic doses of quinine for the control 
 of malaria, and not until much later did they distribute quinine free of cost. 
 The latter measure of health protection was not adopted until long after the 
 free distribution of diphtheria and tetanus antitoxins and other curative and 
 prophylactic sera and of vaccine and various bacterial vaccines. In Balti¬ 
 more the records show that far more deaths were credited to malaria than 
 to small-pox, and for many years malaria certainly killed more than did 
 diphtheria. 
 
 For illustrations of the effectiveness of sanitary measures and cinchoniza- 
 tion of populations upon the course of malaria, long before the discovery of 
 the malarial parasites and the influence of the mosquito in their spread from 
 man to man, it is only necessary to follow the epidemiology of this disease in 
 England, in western Europe, and in the northern States of America. 
 
 Malarial fevers, in severe and fatal form at least, had disappeared from 
 large sections of England, France, and Italy, and even the Low Countries, 
 long before the discovery of the causal agents and their spread by intermediate 
 hosts, under treatment, both curative and preventive, by “ the bark ” and 
 through measures directed against standing water and putrefaction of vege¬ 
 table material on the marsh-effluvia theory. The non-contagious character of 
 malaria was well established centuries ago and of yellow fever early in the 
 nineteenth century. The experiments of Ffirth and of Potter showed as conclu¬ 
 sively as did those of the Reed Commission nearly 100 years later that yellow 
 fever can not be spread by fomites, and furthermore proved that in the height 
 of the disease successful transmission from one human being to another by 
 direct inoculation of the black vomit and of whole blood into the stomach is 
 not practicable. 
 
 Typhus or goal fever was shown in Mead’s time to be successfully combated 
 by measures directed toward personal cleanliness, such as shaving, hair-cutting, 
 bathing the body, and the destroying or disinfecting by heat or chemicals of 
 clothing, bedding, and the like. This fact was amply verified later by Pringle, 
 Monro, Lind, John Howard, and others. The relation of overcrowding, famine, 
 and wars to the spread of typhus fever was as well or even better appreciated 
 then than at present. Indeed, typhus fever in epidemic form had died out in 
 western civilization long years before the relation of the body-louse to the 
 transmission of the disease was discovered. Thus, by the middle of the nine- 
 tenth century, typhus had, without any special sanitary measures directed 
 against it by public-health authorities, become a disease of comparative rarity 
 except in Ireland, Poland, Russia, and the poorer parts of Germany, Italy, and 
 southeastern Europe, in which localities the mass of the people was poverty- 
 stricken and lived continuously in those conditions of filth that favor vermi¬ 
 nous infestation. 
 
102 
 
 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 In English, and even in Scotch cities, without organized health departments, 
 typhus fever became relatively uncommon and was confined to the very poor and 
 to Irish immigrants, by whom it was being constantly imported. After 1840, 
 the epidemics of this disease in Baltimore, as will be shown later, were imported 
 from one or the other of its homes in Europe and spread only among those 
 uncleanly through poverty and ignorance. 
 
 It will be recalled that long before the modern revival in sanitation, the 
 great advances in knowledge of micro-parasitology, and the general acceptance 
 of the germ theory of the causation of the communicable diseases, the idea 
 (with which from their practices it is legitimate to infer that the ancients 
 were familiar) that causation of the acute intestinal diseases is intimately 
 associated with pollution of drinking water with human excreta had been 
 revived or rediscovered. It has been shown in a previous chapter that David 
 Monro recognized this association in 1763. Parkes (38) lias pointed out that 
 diarrhoeal diseases were attributed to impure drinking-water at Gottingen in 
 1760, at Saarlouis by Walz in 1822, at Mayence by Muller in 1843, and at 
 Vienna by Richter in 1848. By Austin Flint (39) at North Boston, N. Y., in 
 1843, and in England by Carpenter (38) in 1852, Rauth (38) in 1856, and very 
 conclusively by Budd in 1859, the important relation between the spread of 
 typhoid fever and polluted drinking-water was shown. The possibility of the 
 transmission of cholera by drinking-water was pointed out by Jameson (38) 
 in India in 1820, and by Muller (38) in Hanover in 1848. This means of 
 transmission of cholera was clearly established by the work of Snow (40) in 
 1849, and especially by the experiences in connection with the celebrated 
 Broad Street pump in London in 1854. The masterly paper of Snow in 1849 
 on the pathology and mode of spread of cholera appeared some years after the 
 great sanitary reforms in London and certain other British cities in regard to 
 purer water-supplies and more effective methods of sewage disposal had been 
 undertaken on the old miasma theory. Snow argued that, since the primary 
 and essential lesions of cholera are in the intestines and the materies morbi 
 must be present and capable of multiplying in the exudation from the mucous 
 membrane of these organs, the disease must be disseminated from sick to well 
 through the intestinal discharges. From a large number of experiences drawn 
 from London and elsewhere he arrived at two important generalizations; first, 
 that numerous opportunities existed for the spread of cholera in households 
 by transferring cholera dejecta to the mouths of attendants and others from 
 stools and soiled bedding directly by the hands or indirectly through foods; 
 and, second, that drinking-waters were impregnated with the unknown causal 
 agent of cholera by contamination from drains, cesspools, and streams polluted 
 with the intestinal discharges of cholera patients. He, therefore, advised that 
 attendants upon cholera patients should wash their hands before eating, that 
 soiled bed-linen should be boiled, and that fruit hawked about the streets (for 
 the contamination of which there were many opportunities) should be avoided. 
 Against infection by drinking-water Snow was no less definite: 
 
 “ And, lastly, whilst cholera remains in the country, people should avoid using water 
 which receives the contents of drains or sewers, or the refuse of persons navigating 
 the water. Since anything touched by the hands may enter the mouth, it would be 
 desirable to avoid even washing with such water; and, at all events, when no other 
 water can be obtained, so much of it as is used for drinking and culinary purposes 
 should be filtered and well boiled.” 
 
PUBLIC HEALTH ADMINISTRATION OF BALTIMORE 
 
 103 
 
 As late as 1873 Budd (41) felt it necessary to submit data to prove that 
 “ typhoid fever is a contagious fever propagated by a specific poison/’ that the 
 intestinal lesions are the characteristic feature of the disease, and that “ what 
 is cast off from the intestine is incomparably more virulent than anything else.” 
 While strongly imbued with the idea that the disease could be spread through 
 the air, he held the same views regarding the importance of the stools, bedding, 
 and polluted water in the spread of typhoid that Snow had enunciated in regard 
 to cholera. Budd laid great stress upon the importance of the disinfection of 
 stools of typhoid patients, and he even considered it highly probable that the 
 disease is spread by means of milk and butter. The demonstrations of Snow 
 and Budd of the important relation between polluted water and the spread of 
 cholera and typhoid exercised without doubt a considerable influence in 
 accelerating the movements already on foot to secure purer drinking-w r ater and 
 safely to dispose of human dejecta, but their discovery of the role played by 
 direct infection by the hands and of indirect infection through foods con¬ 
 taminated with the stools of those ill with these diseases did not bear fruit for 
 many years. It must be recalled that the importance of infected milk in the 
 transmission of typhoid, scarlet fever, and diphtheria was proven in the ninth 
 decade of the last century as the result of epidemiological studies made without 
 the assistance of the methods of micro-parasitology. Snow and Budd made 
 the additional very important discovery, namely, that unsanitary conditions, 
 such as overflowing and unprotected privies and cesspools and water polluted 
 with night-soil and other putrescible matters, do not of themselves give rise to 
 cholera and typhoid fever, but act as vehicles of transmission of their causal 
 agents after these diseases have been introduced into communities. So deeply 
 rooted in men’s minds was the miasma theory in relation to the causation of 
 the acute intestinal disease that it continued to flourish under the guise of the 
 sewer-gas theory, overthrown in the later years of the nineteenth century by 
 exact studies in micro-biology. 
 
 At the beginning of the nineteenth century some cities in Europe and in 
 America returned to the ancient practices of obtaining general water-supplies 
 from a distance, often from unpolluted water-sheds, and of constructing 
 better and more adequate sewers. In these undertakings the inhabitants 
 were influenced in part by the wisdom of the ancients and in part by the 
 miasma theory of the origin of certain diseases. London and certain German 
 cities which were not convenient to unpolluted lakes and streams had adopted 
 by 1850 filtration systems of one kind or another. In many cases filtration 
 resulted in clarification without purification. From this time on and until 
 the development of water bacteriology, a reasonable degree of control of puri¬ 
 fication was maintained at some places by the use of the methods of chemical 
 analysis. 
 
 The establishment of thoroughly efficient systems of water and sewage puri¬ 
 fication by the filtration method would be difficult, though not impossible 
 without the discoveries of micro-parasitology. This does not, however, vitiate 
 the argument, for in the case of both water and sewage this method is only one 
 of several. Many cities, especially those situated on or near sea-coasts or on 
 large rivers, obtain pure water and dispose of sewage satisfactorily without 
 employing the filtration method for either. A knowledge of micro-parasitology 
 
104 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 was certainly not necessary to guide Liverpool, Glasgow, and other cities to 
 obtain pure water from distant lakes, Munich from nearby mountains, New 
 York and Boston and great numbers of other cities from protected water-sheds, 
 Chicago to divert sewage outfalls from water intakes, and to disclose the 
 influence of large storage reservoirs upon water purification. The same may 
 be said of water purification by chlorine and other chemicals. Sewage puri¬ 
 fication by filtration is and probably will continue to be the exception and not 
 the rule. After all, it is by the incidence and mortality of the intestinal dis¬ 
 eases, rather than by the tests and standards of micro-parasitology, that these 
 questions are judged. It is not sought here to disparage these methods, the 
 great importance of which will receive proper consideration in future chapters, 
 but to point out that without them man possessed methods to obtain pure 
 water-supplies and to construct safe methods of sewage disposal. Much more 
 important agents to these ends than micro-parasitology were the invention and 
 perfection of the steam-engine and the electric dynamo, without which many 
 modem cities could hardly have been developed in their present form. 
 
 That the dangers of polluted water were realized in early Baltimore is 
 attested by the facts that the commissioners appointed in 1803 to report on a 
 general water supply were instructed to select a stream “ for a copious and 
 permanent supply of wholesome water,” and as early as 1817 ordinances were 
 passed designed to protect springs and wells from nearby privies and cesspools. 
 Except where religious doctrines and racial prejudices have acted as con¬ 
 trolling factors, as among the Jews, peoples of western civilization did not, 
 until recent years, beyond avoiding food evidently tainted by putrefaction, 
 concern themselves with the relation of foods to the spread of diseases. It is 
 probable that the revival of the old germ theory of disease, or rather the demon¬ 
 stration that certain dangerous affections transmissible from food animals to 
 man are caused by living parasites, is to a considerable degree responsible for 
 the inauguration of the modern system of food inspection designed to protect 
 man against anthrax, glanders, tuberculosis, actinomycosis, and trichinosis. As 
 a matter of fact, however, the identity of most of these diseases in man and in 
 the food animals was established at least as much by pathological anatomy as 
 by micro-parasitology, and the relation of milk to the spread of such diseases 
 as typhoid fever, scarlet fever, and diphtheria was established before the 
 influence of micro-parasitology was brought to bear upon public-health admin¬ 
 istration. 
 
 It is clear, then, that, long before the days of modern micro-parasitology, 
 there existed abundant knowledge and experience upon which to base large 
 schemes of sanitation and of personal restriction for the control of morbidity 
 and mortality of certain diseases. Some other reasons than ignorance and lack 
 of ideas and methods must be found to explain dilatoriness of action. Some 
 of these reasons are not difficult to find. 
 
 Europe, after the fall of Rome, through the Bark Ages, the Middle Ages, 
 and well into the present era, was essentially barbarous. Wars, famine, poverty, 
 and pestilence were the natural order. The great mass of the people were 
 little better than slaves, their bodies to secular and their minds to ecclesiastical 
 princes—two masters often joined in the same person. Hence, man’s intellect 
 was dwarfed by superstition, religious intolerance, and ignorance. Since the 
 chief outlet for talent was centered in the church, secular callings for the few 
 
PUBLIC HEALTH ADMINISTRATION OF BALTIMORE 
 
 105 
 
 who were able to rise and to make a choice were at a discount. In cities, 
 streets were narrow, winding, and filthy, and the dwellings were not only 
 ill-adapted for such use, but were often insufficient in number. As late as 
 1830, 18,000 people in Hamburg lived in cellars, or tunnels, to which daylight 
 never penetrated, and the walls and floors of which were wet and befouled with 
 garbage and human excreta. To go back no further than to the fifteenth cen¬ 
 tury, the Hundred Years War had desolated large areas of Europe. As a 
 result of the Thirty Years War, the population of Germany is said to have 
 fallen from 20,000,000 to 4,000,000. The wars of Frederick the Great left 
 Prussia and Silesia and Saxony impoverished and the populations greatly 
 reduced. The condition of much of France for over 100 years before the 
 Revolution of 1789 was one of impoverishment. Italy and the Low Countries 
 had been repeatedly ravished. Spain, the home of intolerance and of popular 
 ignorance and poverty, was in decline. In Russia and southeastern Europe, 
 tyranny, poverty, and ignorance were even more marked. Such was the 
 continent that faced the wars of the French Revolution and of the Napoleonic 
 era. In no country of Europe, not even in England, had the sanitary improve¬ 
 ments and measures of the Romans survived. The minds that planned and the 
 hands that built the great cathedrals at Paris, at Rheims, at Cologne, and else¬ 
 where on the continent, and the Abbey of Westminster and the great English 
 cathedrals, did not reproduce or even keep in repair the sanitary sewers and the 
 pure-water systems of the Roman civilization. Even with the wealth of the 
 church and the cheapness of labor, the time occupied in the erection of the cathe¬ 
 drals was measured by centuries rather than by years. With a few striking excep¬ 
 tions, the relatively small wealth existant was concentrated in the hands of the 
 few—the nobles and the ruling princes—and in the church, and the great mass 
 of the people were in poverty. The middle class, represented largely by organ¬ 
 ized artisans, merchants, and bankers, was relatively small and the markets 
 were restricted. 
 
 The revival and growth of sanitary reforms and systems of public health 
 administration were impossible until the human intellect was unshackled from 
 the chains of antiquity and religious superstition, and the dense ignorance 
 and poverty imposed by secular and ecclesiastical tyranny were in some con¬ 
 siderable degree overcome. These chains were first cast off in Italy, France, 
 and England as the result of the growth and development of the spirit of scep¬ 
 ticism and of inquiry in the fifteenth, sixteenth, seventeenth, and eighteenth 
 centuries which brought about religious and political freedom, enormous 
 expansion of knowledge, and the production and accumulation of wealth. 
 
 The wonderful outburst in certain Italian cities of intellectual freedom, 
 associated also with the gaining of great wealth from art, manufacture, banking, 
 shipping, and other great commercial undertakings, was followed by a revival 
 of interest in public health and the reestablishment of health departments and 
 the development of civic improvements of a sanitary nature. Under constant 
 threat of plague from the Turkish dominions, the maritime cities of Italy 
 developed the modern quarantine system. But, with the loss of trade and the 
 consequent decline of wealth and intellectual culture, and of their diffusion in 
 the population following the development of the ports of northern Europe, and 
 the loss by conquest of the relatively incomplete degree of popular political free¬ 
 dom, public health administration and general sanitary improvements not 
 
106 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 only ceased to advance, but lapsed into conditions as primitive as those of Spain, 
 France, and central and northern Europe, and lay dormant until the general 
 sanitary revival of the last quarter of the nineteenth century. 
 
 Just as in England after a long struggle, the human intellect first gained a 
 goodly measure of freedom, so England was the first country to produce in 
 numbers distinguished investigators in all branches of knowledge and to 
 attain popular government and considerable wealth, with the general diffusion 
 of both knowledge and wealth among the people. There is ample reason, there¬ 
 fore, why that country should have early taken the first place in Europe in 
 public-health investigation and administration. It was not until the nine¬ 
 teenth century, however, that, even there, conditions were favorable for any 
 considerable progress. Nor is it surprising that people of the same blood, 
 with more personal freedom and a wider diffusion of knowledge among the 
 general population, though with less wealth and a smaller productivity in 
 fields of scientific inquiry, should, in the early history of their municipalities 
 (as in Baltimore), while following very closely the traditions and methods of 
 the mother country, have anticipated the English in municipal health legisla¬ 
 tion and in the establishment of boards of health with medical officers. It is 
 not strange that, so long as few striking contributions were made to general 
 and to medical knowledge and until wealth was accumulated and became more 
 generally diffused, American municipal public-health administration should 
 have, in many respects, lagged behind that of England. A notable point of 
 difference was dependent upon the fact that the early advances made in 
 England were in large degree due to the researches and methods inaugurated 
 and supported by the General Government, while in America the influence of 
 the central and State Governments was, until recent years, practically nihil. 
 The backwardness of public-health administration and general sanitation in 
 French municipalities, until comparatively recently, was doubtless due in 
 great part to the struggles to obtain political freedom and to obtain wealth. 
 Napoleon I, however despotic in some respects, in the main adhered to the 
 basic principles of the saner Bevolutionists and preserved to the French people 
 the freedom they had gained. He not only fostered science and education, but 
 besides other great improvements, drained large areas of France and in Paris 
 constructed a new water-supply system and numerous sewers. German munici¬ 
 palities were notoriously lacking in these respects until the increase in pros¬ 
 perity and in popular education and the acquirement and exercise of a greater 
 degree of local self-government some years after the Franco-Prussian War of 
 1870. Even in that country sanitary progress began in the free cities of 
 Hamburg and Frankfort. 
 
 Under autocratic governments, the ruling classes are indifferent to distress, 
 disease, and death among the poorer and more ignorant classes, and these people 
 are comparatively helpless, partly on account of superstition and partly on 
 account of their ignorance concerning measures that would improve their 
 condition and their lack of power to extort them. Their ignorance has no 
 doubt been influenced in some degree by the very diseases under which they 
 labored. Autocratic governments do not inaugurate measures for the pro¬ 
 tection of the general population against disease until a stage of enlightened 
 self-interest is attained, or until the demands for reforms become so loud and 
 threatening that some concession is made. When these conditions obtain, 
 
PUBLIC HEALTH ADMINISTRATION OF BALTIMORE 
 
 107 
 
 popular government is in sight. Great and rapid advances in public-health 
 administration and practice have come in modern times from peoples with 
 wealth and with popular governments. Under autocratic governments, knowl¬ 
 edge and wealth and a free spirit of inquiry have rarely, if ever, been diffused 
 among the general population. 
 
 In free governments, as in American cities, with all classes, and average 
 citizens in particular, jealous of private rights of both property and person, 
 citizens are loath to pass laws of a restrictive nature and are intolerant of 
 restrictive measures imposed upon them by elective or appointive officials. 
 Indeed, they reserve the right to have all laws and regulations submitted 
 through their courts to tests not only of constitutionality, but of reasonableness. 
 It is not until the average citizen has acquired a degree of information through 
 which he becomes convinced that such measures are not only reasonable, but 
 that they will tend to act to the advantage rather than to the disadvantage of 
 himself and his dependents, that he will consent to impose the restrictions 
 involved. Even those measures, the wisdom of which he is convinced, are often 
 postponed, or, if undertaken, are, on account of the cost, prosecuted in a half¬ 
 way manner. After the citizens have consented to a course, their instruments, 
 to whom are committed the framing of necessary laws and regulations and 
 their administration, and the planning and construction of necessary works 
 and buildings, may, and only too often do, lack in the knowledge, judgment, 
 and efficiency necessary for success. There is a wide gap between recorded 
 knowledge, both general and particular, in connection with any subject and 
 the proportion of knowledge on that subject possessed by those to whom fall 
 the opportunity and responsibility to apply it to popular use. 
 
 It is evident, therefore, that to attain a high degree of efficiency in the con¬ 
 trol of disease, a people must have obtained a considerable amount of knowl¬ 
 edge, freedom, and wealth and to be able to obtain health officials with com¬ 
 prehensive and accurate information concerning both the natural history of 
 diseases and the fundamental and applied sciences. These several conditions, 
 necessarily precedent to successful efforts to control the incidence of disease, 
 have never fallen together in Baltimore (nor in any other municipality for 
 that matter), as will be abundantly shown in succeeding chapters. It will suffice 
 to point out here that the failures are to be laid to both public and officials. 
 For over 100 years the needs in connection with general measures outstripped 
 in growth both the intelligence and the wealth of the population, and, until 
 the present time, the general officials often, and the chief health officials nearly 
 always, were so fettered by ignorance and so swathed in the bands of tradition 
 that at critical times the former were incapable of demanding and the latter 
 were incapable of creating a fully rounded health department. 
 
 The peoples whom the end of the eighteenth and the first half of the nine¬ 
 teenth centuries found with liberal institutions, after heavy struggles, were 
 busy consolidating and extending their gains. The mere possession of methods 
 was not sufficient in itself among peoples not ready to use them routinely and 
 logically. It is a striking fact that man, although he had formulated long 
 years before the beginning of the nineteenth century practically the same 
 methods of control that he now uses against most, at least, of the typically con- 
 tactive diseases, has been much more willing to attack the nuisance or effluvial 
 
 8 
 
108 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 diseases. His actions in this respect were probably determined by several 
 considerations. In the first place, the necessary measures were directed to 
 things rather than to persons, and therefore violated to a lesser degree his 
 inherent sense of personal liberty and interfered less with his capacity to earn 
 a living. Secondly, after he had acquired knowledge and wealth, and both 
 these attributes had become diffused with a degree of equality hitherto un¬ 
 known, he developed a sense of decency, a feeling of self-respect and personal 
 pride, a sense of the fitness of things, which resulted in a marked change in 
 manners and customs, both public and private. As a result, conditions of living 
 and surroundings that had previously offended the few were by the end of the 
 eighteenth century distasteful to the many. It is not at all strange that the 
 English, to whom wealth with the power to use it came first, should have been 
 the first as a nation to emerge from the relative barbarity of the sixteenth and 
 seventeenth centuries and to acquire and then to gratify a taste for decency 
 in municipal, household, and personal surroundings, nor is it remarkable that 
 this attitude should be reflected to their descendants in North America. In 
 the third place, efforts to influence the environment promised a richer return 
 than those expended against persons, for they had some striking results to 
 their credit, while on the other hand experience had shown that, so far as 
 attempted, measures to restrict diseases spread especially by personal contact 
 had very generally failed signally. 
 
 In the light of these reflections it will not seem remarkable that in Baltimore, 
 as will appear in later chapters, during most of the nineteenth century, the 
 efforts of the health and other civic authorities were directed within the city 
 chiefly against diseases classed as miasmatic, efiluvial, or infectious, and that, 
 with the exception of small-pox, the contactive diseases received but scant 
 attention. The sequel has shown that, imperfect and inadequate as were their 
 applications of the measures used, and far short as they fell of what they might 
 have accomplished, the early Baltimoreans took the better of the two bets. 
 
 The primary and fundamental steps in the logical application of Mead’s 
 recommendations in controlling a given disease are the early recognition and 
 the reporting of all cases to the authorities, and yet it was not until 1889 in 
 London and 1882 in Baltimore that laws were passed requiring routinely the 
 prompt reporting of certain acute febrile diseases. Though in England and 
 Scotland notification of febrile diseases was enforced in a few urban districts 
 as early as 1876, it was not widely adopted before 1882. Prior to the act 
 of 1889, making notification compulsory for all London but optional else¬ 
 where, 17 of the 28 greater towns of England had adopted it and 11 had not. 
 The latter act specified as reportable diseases, cholera, small-pox, scarlatina, 
 typhus, enteric, relapsing, and puerperal fevers, diphtheria, and erysipelas. 
 In Baltimore, the very incomplete list embraced only small-pox, scarlet fever, 
 cholera, yellow fever, malignant diphtheria, and varioloid, all but one of which 
 were then locally regarded as typically contactive in mode of spread, the 
 essential cause of none having been discovered up to that time, and that of 
 only two (cholera in 1883 and diphtheria in 1884) having been conclusively 
 identified up to the present. The other diseases since added to the list by 
 city ordinance are membranous croup, measles, mumps, and whooping-cough 
 in 1890, and typhoid fever in 1895. 
 
PUBLIC HEALTH ADMINISTRATION OF BALTIMORE 
 
 109 
 
 It is clear that the earliest of these laws were passed before the discoveries 
 of modern micro-parasitology had begun to exert any direct and controlling 
 influence upon public-health administration. In Baltimore the law of 1882 was 
 passed during the height of one of the most severe epidemics of small-pox the 
 city had experienced. From the evidence at hand it is clear that this was 
 inspired by an attempt to make small-pox a reportable disease permanently, 
 and advantage was taken of the opportunity to include the other diseases, some 
 of which had been widely epidemic and very fatal a few years before. 
 
 Besides those considerations of a general nature, there were others of a 
 more specific character that obviously impeded the development of municipal 
 sanitation and public-health administration in the latter part of the eighteenth 
 and throughout the nineteenth centuries. The most important of these was 
 the very rapid and unprecedented growth of urban populations, due not to 
 excess of births over deaths, but to immigration, either, as was particularly 
 true of Great Britain, a migration from country and village to cities, or, as in 
 North America, an immigration from abroad as well as from the above- 
 mentioned sources. These new elements were disturbing factors in many w 7 ays. 
 Influenced by a lively sense of self-interest and lacking, at least in the be¬ 
 ginning, a personal sense of civic loyalty and responsibility engendered by 
 continuous residence and by generations of family associations and traditions, 
 their presence and activities upset the homogeneity of the population in cus¬ 
 toms of social and business life, in kinds and directions of trade and manu¬ 
 facture, in education, in politics, and often in religion. Especially disturbing 
 in these ways were, of necessity, emigrants from foreign countries, on account 
 of the wide divergences of customs and prejudices, and above all on account 
 of differences in speech. A large proportion of all immigrants to cities, whether 
 from the same or foreign countries, were deficient in education and training 
 and were poor in purse. Some at once, and many more with even slight adversi¬ 
 ties in business and trade, became burdens upon the cities. Their mere pres¬ 
 ence diverted work from old to new channels, and particularly in times of 
 business boom, stimulated building, increased the cost of living, and in other 
 ways upset the balance of life. They caused overcrowding in dwellings, added 
 to the cost of the removal of waste, and their presence resulted in the con¬ 
 struction of dwellings at a rate that far outstripped the growth of paving, 
 sewers, and water supplies. Thus, there have so often resulted cities more 
 or less solidly built up in the central area, with durable and well-constructed 
 pavements, surface water and sanitary sewers, and a generous water-supply, 
 bordered by a second area, with poorly paved or unpaved streets, with sewers 
 and water-pipes but incompletely extended, and with conditions of general sani¬ 
 tation varying in its different parts from a semi-urban to a village state. 
 Beyond this there is a larger or smaller zone, with scattered villages or in a 
 partly cultivated rural state, where the general sanitation is of the crudest type. 
 Parts or all of this zone are finally annexed. It not infrequently happens, 
 therefore, that in a North American city under the influence of rapid growth in 
 population, more than half the territory and a third or more of the population 
 are without the area having complete sanitary arrangements in regard to 
 paving, sewerage, water, and garbage removal. Even when the money can be 
 raised to furnish sanitary necessities, the work occupies years, and before it is 
 
110 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 completed another annexation takes place. It is only within a comparatively 
 short time that parts of the second and third zones have been paved, sewered, 
 and watered by the owners as development takes place. Migrants, particularly 
 from other countries or distant parts of the same country, have often brought 
 in and kept alive diseases that were dying out, or have imported a disease in 
 more virulent type. Well-known examples are the importation of typhus into 
 Scotch and English cities by Irish immigrants, and the importation of typhus, 
 small-pox, measles, scarlatina, and other diseases into Baltimore by Irish and 
 German immigrants. 
 
 Thus it is that, with few exceptions, very rapid growth in population and 
 territory must react unfavorably upon both general sanitation and personal 
 hygiene in a city. In Baltimore the action of all these factors has been particu¬ 
 larly striking. 
 
 The great influence of the application of statistical methods to the study 
 of the natural history of disease and the problems of public-health adminis¬ 
 tration has also been either overlooked or not duly appreciated. Used first in 
 these connections in the construction of life tables as a basis of insurance, these 
 methods were then applied by publicists and statesmen in determining the 
 laws which govern the growth of population and wealth; by pathological anato¬ 
 mists in the study of the comparative frequency of diseases and of particular 
 lesions; by clinicians, especially the French, in the determination of case 
 fatality rates in different diseases, particularly where certain methods or plans 
 of treatment were concerned; and later by medical men, general statisticians, 
 and public-health administrators in the comparison of salubrity of climate and 
 general environment upon, first, general morbidity and mortality, and, second, 
 particular diseases. Shortly after the middle of the nineteenth century, under 
 the influence of William Farr and his pupils in England, and of Lemuel 
 Shattuck of Boston and of Joynes and Frick of Baltimore in the United States, 
 statistical methods had become a determining force in the study of the natural 
 history of individual diseases and in the whole field of public-health inquiry 
 and administration. The appreciation of statistical methods was not only 
 responsible for discoveries of fundamental importance in these fields, but for 
 the important means of diffusion among people of the knowledge acquired. 
 
 Thus it was, largely at least, a coincidence that the discoveries of modern 
 micro-parasitology and the additional practical methods of disease control 
 derived from them fell at a time when a large and the most intelligent part 
 of mankind was ready to consider and to apply them. With certain notable 
 exceptions these discoveries were not made by public-health officials, who have 
 on the whole, but very clumsily, slowly, and reluctantly, applied them. How¬ 
 ever, instances are not lacking, in the history of Baltimore in particular, of 
 examples of health officials pleading in vain for means and power to under¬ 
 take measures certain to exert a favorable influence on the public health. 
 
 The coincidence of the recognition on the part of the general public of the 
 importance of public-health measures of a wider scope, and the availability of 
 funds to carry them out, with the great discoveries in micro-parasitology, 
 medicine, surgery, and above all in pathological anatomy, during the last third 
 of the nineteenth century, was responsible for the generally prevalent idea 
 that all the knowledge and power of man over the control of diseases are 
 dependent upon them and certain improvements and refinements of methods 
 
PUBLIC HEALTH ADMINISTRATION OF BALTIMORE 
 
 111 
 
 arising out of them. Curiously enough, at the same time, some of the labors 
 of previous years began to bear fruit, and, as will be shown later, certain wide¬ 
 spread and conspicuous diseases (measles, scarlatina, typhus fever, and small¬ 
 pox) happened to run into periods of decline, wliich, for some of them at 
 least, is a phase of their natural history, a fact well established since the 
 days of Sydenham. 
 
 Among the many important influences ascribed to modern medical and 
 zoological knowledge has been its effect upon the distribution of the febrile 
 diseases among the old classifications, for due to it the number of affections 
 classed under the nuisance diseases has increased at the expense of the list of 
 those classed as spread by immediate contact. This has largely been brought 
 about by the discovery that the causal agents of certain affections, such as 
 typhus and relapsing fevers, sleeping sickness, and the plague are spread by 
 insects acting either as intermediate hosts or as mechanical carriers, the 
 presence of which beings in man’s environment is governed by conditions 
 associated with nuisances due to lack of cleanliness. Another advance due to 
 this knowledge was the determination that, as a rule, under natural conditions 
 the causal agents of the nuisance diseases enter the system through the skin or 
 by the mucosa of the gastro-intestinal tract, instead of by the lungs only, as 
 was supposed, and by the evidence furnished in favor of the view that the 
 typical contagious diseases of a general systemic type, the eruptive diseases 
 particularly, such as small-pox and scarlet fever, as a class invade the body 
 by the respiratory tract, instead of through the skin, as was often formerly held. 
 
 To be classed among the greatest contributions made by pathological anatomy 
 and by micro-parasitology to the knowledge of the natural history of the 
 febrile diseases applicable to public-health administration are the deter¬ 
 mination of the portals of entry and exit of their causal agents to and from 
 the body and their modes and channels of travel within the body; the charac¬ 
 ters and varieties of lesions produced, particularly those determining a fatal 
 issue; the forces and factors concerned in recovery and particularly in immu¬ 
 nity ; the identity of various diseases common to both man and lower animals; 
 the separation on an etiological basis of the different affections characterized 
 by the same or similar clinical symptoms or anatomical changes; and, finally, 
 a series of methods for both diagnosis and preventive inoculation based upon 
 pathological anatomy, direct microscopy, cultivation, animal experiment, and 
 immunity reactions. 
 
 The application of the methods of chemistry, bacteriology, and zoology to 
 sanitary engineering, and especially to standards of purity of water and of 
 milk and other foods, are of the greatest importance. 
 
 This knowledge in these various fields but slowly penetrated the minds of 
 public-health administrators, and these methods came into use in health depart¬ 
 ments sparingly between 1890 and 1900, more generally in the next decennium, 
 and can hardly be considered to have exercised a controlling influence on 
 public-health administration in Baltimore or in the average municipality before 
 1910. Indeed, it would be difficult to select another branch of municipal 
 government on which scientific discoveries of corresponding importance could 
 have exerted in so leisurely a manner an influence proportionate to their value 
 
 It has been shown that long before the discoveries of modern micro-para¬ 
 sitology man possessed means and methods capable of being used to effect 
 
112 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 considerable control over the febrile diseases; that the placing of the old 
 germ theory of the causation of these diseases upon a firm scientific basis was 
 not the essential or determining cause of the modern advances in public- 
 health activities, and that this practice, as regards the contagious diseases, 
 begun in the fourteenth century in Italy, was transplanted to England in the 
 early eighteenth century, and that in England and elsewhere, particularly in the 
 United States, during the latter part of the eighteenth and the whole of the 
 nineteenth centuries, municipalities attacked the effluvial or nuisance diseases 
 with considerable success, and that the contactive diseases in general have, on 
 the whole, been attacked with a much smaller degree of success than the 
 nuisance diseases. A consideration of general history and of the knowledge 
 of the natural history of the febrile diseases indicates conclusively that until 
 modern man had regained his intellectual freedom, out of which sprang 
 religious and political freedom and wealth, advances in public-health adminis¬ 
 tration were, and in the nature of things could be, but slight, and significant 
 progress in the control of these diseases became possible only when in the latter 
 half of the nineteenth century knowledge and wealth were not only attained 
 but diffused. Hence the following generalizations are warranted: 
 
 1. The change in man’s attitude toward the control of those diseases was 
 the direct result of the revolution in the religious, political, educational, and 
 social status of the common man, proceeding from intellectual freedom, and 
 the effects achieved were due more to the release from inhibitions against the 
 use of existing ideas and methods than to the sudden acquirement of new ones, 
 and, being greatest among peoples who had attained this freedom in the highest 
 degree, were, in any particular place, other things being equal, in direct 
 proportion to the degree of freedom obtaining. 
 
 2 . There is a direct relation between the diffusion of knowledge and wealth 
 among peoples and their public-health activities, and the discoveries resulting 
 in new ideas and methods applicable to disease control and proceeding from 
 intellectual activities along general and special lines in consequence of intellec¬ 
 tual freedom have been submitted to practical application earliest and in the 
 highest degree among peoples with the widest distribution of knowledge and 
 wealth. 
 
 3. It is because the methods of control applicable to them are more imper¬ 
 sonal (involve to a much less extent intimate supervision and restriction of 
 the person and of personal activities) and because they can be so markedly 
 influenced by measures so largely covered by the expenditure of money upon 
 environment, that the diseases formerly attributed to effluvia, or the nuisance 
 diseases, including those now known to be spread by intermediate hosts, have 
 been and are yet more energetically attacked and more successfully combated 
 than the diseases classed as contagious. Such control as has been attempted 
 over diseases believed to be spread by contact has been determined more by 
 horror inspired by the physical deformities or the mode of death characteristic 
 of a disease than by its fatality. The attempts to control the former class of 
 diseases by prevention and abatement of nuisances were logical and in the 
 right direction, and the failure to secure better results was due in greater 
 degree to lack of effective action on conclusions reached than to defects in 
 the premises set up on assumptions and the deductions drawn therefrom. 
 The one-sidedness in the activities of public-health administration in concen- 
 
PUBLIC HEALTH ADMINISTRATION OF BALTIMORE 
 
 113 
 
 trating attention so closely during the nineteenth century upon the nuisance 
 diseases is responsible for the present widespread and deeply rooted belief, on 
 the part of both the public and their administrative officials, that all febrile 
 diseases can be effectively controlled by modifications of environment. 
 
 4. As the methods of substitution inoculation against small-pox were known 
 and practiced long before, and as the prevention of wound infection, includ¬ 
 ing puerperal fever, depends so much more upon measures directed to things 
 and to the control of the acts of personal attendants than upon control of 
 persons affected, it may be accepted as an established fact that, with the 
 exception of a few acute diseases for which they have furnished methods of early 
 diagnosis and of preventive inoculation, such as diphtheria, meningitis, and 
 hydrophobia, modern medical discoveries, including those of micro-parasitology, 
 have exercised as yet no fundamentally important influence upon the control of 
 the diseases classed as contagious, for any recently favorable fluctuations in their 
 incidence and mortality can be adequately explained by other factors. 
 
 o. As modernly acquired knowledge has, for the control of the mass of 
 diseases classed as contagious, added as yet comparatively little in principle 
 to Mead’s recommendations, it is evident that in respect to them the only 
 change introduced in public health practice in recent times is the attempt 
 to apply these measures in a more thorough and systematic manner. Though 
 it has been possible under very favorable circumstances to check small out¬ 
 breaks by their use, or here and there, under ordinary conditions, to restrict 
 the numbers attacked, rarely, if ever, with the exceptions above noted, have 
 any of the diseases classed as typically contagious been curbed when in epi¬ 
 demic cvcle. 
 
 i/ 
 
 It is to be clearly understood that, in connection with the foregoing state¬ 
 ments, there is no intent to disparage in any way the remarkable and pro¬ 
 foundly important discoveries in modern medicine and in the fundamental 
 sciences, particularly in mathematics, physics, chemistry, zoology, and botany, 
 on which it depends, and in the applied sciences of engineering, statistics, 
 genetics, and so forth, on which our knowledge of the natural history of diseases 
 is so largely based and to which public-health administration owes so much, and 
 in all of which discoveries have been gained for knowledge by a comparatively 
 small band of self-sacrificing, devoted, and often brilliant workers, laboring 
 only too often under unbelievable handicaps. No one who has grown up 
 under the influence of this rapid unfolding of scientific knowledge, the most 
 precious possession of man, especially in the biological sciences, during the 
 last 40 years, or who has taken even a small part in its development, can fail 
 to appreciate its importance and significance both generally and in the fields 
 of the natural history of disease and of the development and administration 
 of public-health measures. 
 
 To point out that it was not, as was erroneously supposed in many quarters, 
 the acquisition of a particular branch of this knowledge, but the possession and 
 diffusion of knowledge previously gained, to which recent interest and progress 
 in public-health activities are to be attributed is not to deny its great value. 
 The sloth with which modern medical knowledge, and especially micro-para¬ 
 sitology, has been utilized is the result of the lack of proper appreciation by 
 peoples and their representatives, and in no way reflects upon its intrinsic 
 value. 
 
114 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 Without the firm standing-ground of the exact scientific knowledge gained 
 in this period, it would not be possible to recognize that previous generations 
 possessed powerful weapons for the control of certain diseases or to appreciate 
 how signally they fell short of their full use, nor, on the other hand, could 
 a just estimate be had of how much was accomplished by the application of 
 methods, sound in many respects, but based upon theories exploded by this 
 knowledge. 
 
 The diseases classed by the health authorities and by the physicians generally, 
 in Baltimore, from the earliest times until the last decade of the nineteenth 
 century as infectious, miasmatic, or effluvial, and therefore as nuisance diseases, 
 were malarial and yellow fevers, membranous croup and malignant sore throat 
 (diphtheria), and the diarrhoeal diseases, including dysentery, cholera asiatica, 
 cholera morbus, cholera infantum, simple diarrhoea, and typhoid fever. 
 
 Among the typically contagious diseases were included small-pox and 
 varioloid, vaccinia, scarlatina, measles, whooping-cough, mumps, erysipelas, 
 typhus fever, influenza, pulmonary tuberculosis, leprosy, hydrophobia, men¬ 
 ingitis, poliomyelitis, and the venereal diseases. Tetanus, though not made 
 reportable, was included by inference during the time of its greatest recorded 
 prevalence among the diseases influenced by accident. Diphtheria, by consensus 
 of opinion, was transferred from the nuisance to the contagious diseases during 
 the ninth decade of the nineteenth century. It was not until well after 1890 
 that such diseases of rare occurrence as anthrax, glanders, actinomycosis, and 
 trichinosis were recognized in the department. 
 
 The idea that some of these diseases may be spread in any one of several 
 ways, obvious as it seems, did not occur to the authorities until comparatively 
 recent times, and then only very gradually. 
 
 So firmly is the division of the febrile diseases fixed and interwoven into 
 these two distinct classes in the conceptions and methods of the health and 
 other departments of the Baltimore City government, that any complete study 
 of the methods and results of its public-health administration must be based 
 primarily upon them. Therefore, the study of the administrative efforts of the 
 Baltimore City government to control febrile diseases within the city must 
 embrace: (1) measures of nuisance prevention and abatement directed against 
 nuisance-borne diseases, and (2) measures of restriction and inoculation 
 directed against contagious diseases. 
 
 MEASURES OF NUISANCE PREVENTION AND 
 ABATEMENT DIRECTED AGAINST 
 NUISANCE-BORNE DISEASES. 
 
 The term nuisance, as here used, includes all those conditions hurtful or 
 injurious to health, which originate or propagate in man’s environment. 
 Nuisances in this sense are of two broad classes: Those inherent in the physical 
 characteristics of a place and those brought about by man’s own acts or negli¬ 
 gence. Examples of the first class, which may be properly styled nuisances of 
 location, include marshes, ponds, streams, and ravines. Nuisances of the 
 second class fall into five categories: Those due to artificial changes in the con¬ 
 tour of the surface of the ground, which interfere with the natural flow of water 
 
PUBLIC HEALTH ADMINISTRATION OF BALTIMORE 
 
 115 
 
 and favor the accumulation of dirt (brought about generally by excavations, 
 changes in grades, dams, and irregularities of street surfaces, and so forth) ; 
 those arising from imperfect methods of disposal of organic waste materials 
 (such as the excreta, in the broadest sense, of man and domestic animals, gar¬ 
 bage, offal, street sweepings, and lack of cleanliness of persons and of clothes, by 
 which food, drink, and air are contaminated, or in which lower organisms 
 capable of acting as carriers of pathogenic micro-organisms are bred and 
 supported); those concerned directly with foods (decayed foods, foods from 
 diseased animals or plants, and foods inadequate in themselves); those asso¬ 
 ciated with buildings in which man works or lives; and, finally, those connected 
 with the things with which man works. 
 
 Nuisances of either class may be present upon either public or private 
 domains. In Baltimore the topography of the location not only gave rise to 
 numerous nuisances of the first class, but rendered the prevention and abate¬ 
 ment of nuisances of the second class both difficult and expensive. Had the 
 town been located on the high ground and grown toward the water, or had the 
 whole area been graded in the beginning for the laying out of a large city, 
 its nuisance problems would have been comparatively simple and its whole 
 sanitary history would have been different. As it is, the town was planted on 
 low grounds, it was bordered on three sides by marshes, through which flowed 
 streams subject to overflow, and on the fourth side it was overlooked by hills 
 separated by ravines. Since the low ground was settled first, only part of the 
 material obtained in grading the hills was utilizable for filling the low-lying 
 section, through or over which the surface water had to flow. The work of 
 grading both sections and of filling and raising the lower portion of the city 
 along the water-front and the four streams was expensive and difficult. In the 
 nature of the case, the problems could be worked out only slowly. It is clear 
 that the main questions presented embraced an abundant and safe water-supply; 
 the collection and diversion of the flow of all household waste, including 
 excreta, to the southeast; grading, filling, and paving; the construction of 
 conduits to lead surface-water to the water-front and to prevent standing water; 
 the removal and disposal of garbage, ashes, and other waste; and the develop¬ 
 ment and practice of decent household and municipal housekeeping. The 
 remainder is simple. None of these matters has ever been brought to com¬ 
 pletion, and the whole history of nuisance control represents a series of discon¬ 
 nected, bungling efforts to attain an impossible goal. In actual practice these 
 efforts were directed simultaneously against both classes of nuisances, and the 
 only clear-cut division of nuisances, from the standpoint of administration, is 
 into nuisances on public and nuisances on private domains. Even here there 
 is some overlapping. As closely as circumstances will allow, nuisances, however 
 arising, will be considered under these two headings. 
 
 I. PREVENTION AND ABATEMENT OF NUISANCES 
 
 ON PUBLIC PROPERTY. 
 
 DREDGING AND FILLING. 
 
 The dredging of the basin and the mouths of the main streams, especially 
 Jones Falls and Harford Run, has been executed in general by the city 
 commissioners, the port wardens, or the harbor board. To these authorities also 
 
116 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 has fallen, in the main, the duty of filling the marshes, particularly those bor¬ 
 dering on these two streams, and for this the dredged material has largely been 
 used. Similarly, authorities other than the Health Department have had charge 
 of sewer building, and the walling in and the covering of the four streams. 
 The health authorities, so long as they were responsible for the disposal of ashes 
 and rubbish, used these for filling in low grounds on public as well as on 
 private domains. 
 
 GRADING AND PAVING. 
 
 On account of the topography of Baltimore, the amount of grading necessary 
 in the laying out of streets and the filling of low grounds was considerable. In 
 the early days of the city’s growth, the filling in of the marshy land along 
 the water-front, especially bordering the course of the four streams, Harford 
 Run, Jones Falls, and Schroeder’s and Chatsworth’s Runs, comprised the chief 
 grading activities. Much of the material for this purpose was dredged from the 
 basin and the mouths of the streams. Later, with the growth of the city to 
 the north beyond Saratoga Street, and west and east, a series of high and 
 irregular hills were cut through and smoothed off, and the valleys between 
 them raised. This required an enormous amount of labor. The margin of the 
 built-up section has always presented a number of ravines to be filled. For 
 this purpose soil obtained from leveling and from the excavations for buildings 
 and, of late years, coal ashes and cinders, have been used. In this way the 
 use of ravines and other low places, with which the border of the city has 
 always abounded, as public dumps, has done away with many nuisances and has 
 been of material assistance in grading. 
 
 As early as 1782 the grading and paving of the streets and sidewalks was 
 undertaken in a systematic manner under the direction and control of a 
 special commission established for the purpose by the legislature. At this time, 
 Market or Baltimore Street, the main thoroughfare, was in a deplorable con¬ 
 dition and in wet weather was almost impassable. The street pavements, at 
 first confined to the business sections, were of rough cobblestones, set in sand 
 on top of the clay soil. By an ordinance in 1819, all future paving was to be 
 done with river or pebble stone (called cobblestone) from 7 to 3 inches in 
 diameter and at least 5 inches in length, set upright in a bed of sharp sand 
 at least 1 foot in depth. Until 1910, except where Belgian blocks (granite 
 blocks) and occasionally asphalt were substituted in a few business streets and 
 prominent thoroughfares, the typical cobblestone-paved street was elevated in 
 the center and sloped to the sides, which were bordered by gutters laid with 
 smaller and flatter cobblestones. Set in sand over a clay base and with poorly 
 matched stones, these pavements under heavy traffic developed larger and 
 smaller holes in which water and organic materials collected. The private 
 alleys (varying in width from 3 to 18 or 20 feet) which intersect every block 
 were gradually paved with cobblestones in most of the closely built sections 
 of the city. These pavements were concave with a central gutter for the con¬ 
 duct of storm-water and the household wash-water, which poured into it 
 through rough and for the most part open drains which traversed the neighbor¬ 
 ing backyards. As these pavements were often poorly laid and ill adapted to sup¬ 
 port the heavy garbage and ash carts that passed through the alleys, they soon 
 became full of holes, in which collected stagnant water, garbage, and stable 
 
PUBLIC HEALTH ADMINISTRATION OF BALTIMORE 
 
 117 
 
 manure. In many parts of the city the alleys were catch-basins of filth, for into 
 them were deposited garbage and ashes for collection and all sorts of household 
 rubbish. The condition of the unpaved alleys was worse. The alleys, except 
 when they have occasionally been taken over by the city, are private, belonging 
 to the owners of the adjacent properties along the rear or side of which they 
 run, and, therefore, their paving is at the expense of the owners. 
 
 The report of the city engineer in 1911 gave the street mileage of the 
 different kinds of pavements as follows: Cobblestone, 354.82; Belgian block, 
 43.49; sheet asphalt, 19.23; vitrified brick, 19.15; wooden block, 1.63; ordi¬ 
 nary macadam, 56.01: bituminous macadam, 2.73; bitulithic, 10.10; cement 
 surface, 2.01; unpaved 57.73. Thus of the total mileage 62.5 per cent was 
 cobblestone, and of the total mileage of what may properly be called street 
 pavement (excluding the ordinary macadam and the unpaved streets), 78 per 
 cent was cobblestone. 
 
 During the early days of the city’s history, the sidewalks were largely of 
 brick, retained at the gutter side by a curbing of granite. Of late years, cement 
 has been generally used, and much of the former brick paving has been replaced 
 with this material. 
 
 Since 1912, under the stimulus of Mayor James H. Preston and following 
 the construction of the new sewerage system, many miles of streets have been 
 regraded and paved with smooth pavements, edged by well designed and con¬ 
 structed gutters with smooth surfaces. 
 
 In 1916 and 1917, all of the nearly 3,000 roughly paved private alleys were 
 condemned as nuisances by the health department and ordered regraded and 
 paved with smooth pavements by the highways engineer at the expense of 
 the owners. When this work was suspended during 1918 on account of the 
 war, this undertaking had been completed in about half of these alleys. 
 
 STREET CLEANING AND GARBAGE REMOVAL. 
 
 Since the passage of Ordinance 15 in 1797, it has been the duty of the 
 owners or occupiers of houses and lots within the city to keep the sidewalks 
 clean and the gutters clear, and it has been the function of the city government 
 to clean the streets or public highways and to remove the sweepings. The latter 
 duty was exercised under the direction of the city commissioners until 1826, 
 when it was transferred to the commissioners of health. In 1882 it was taken 
 over by a newly created department of the city government, the department of 
 street cleaning. 
 
 It is not certain when the removal of garbage and ashes was first undertaken 
 by the city. It is probable, however, that until 1821 each householder made his 
 own arrangements for this purpose, and it is likely that it was fed to pigs 
 within the city. In 1821 the city undertook the removal of garbage and ashes, 
 and the superintendents of street cleaning, offices established in 1798 under 
 the city commissioners, were required by ordinance to collect garbage on three 
 days of each week between May 1 and November 1, and from this time the 
 removal and disposal of garbage and ashes have been conducted under which¬ 
 ever department of the city government was responsible for street cleaning. 
 
 In 1826, the commissioners of health let out the cleaning of the streets and 
 the removal of garbage by contract. The total sum appropriated to the health 
 
118 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 department for these purposes in 1827 was $3,500. Since 1828, the manure 
 obtained from the streets has been sold, and the income from this source in 
 considerable part paid for the work. Thus, in 1820, of $5,500 available for 
 those services, $1,500 was derived from the sale of manure. 
 
 It is related by Wynne that in 1849 the city, for purposes of street cleaning, 
 was divided into five districts, the cleaning of each of which was let to separate 
 contractors. Each contractor received in payment the street refuse, which was 
 sold as manure, and about $1,000 in money. 
 
 The streets received attention in proportion to their tendency to collect 
 filth, but never more than twice a week, and more usually once in two weeks. 
 The numerous narrow alleys and courts, inhabited by the poor and the deposi¬ 
 tories of garbage and worse, received little attention and were generally in a 
 filthy condition. The most effective scavengering in these districts was per¬ 
 formed by swine, which roamed through them at pleasure. The most effective 
 street cleaning was performed by the copious showers, which were most fre¬ 
 quent in summer. 
 
 In 1853, the contract system of the cleaning of streets and the removal of 
 garbage and ashes was abandoned, and these services were taken over by the 
 commissioner of health, Mr. Charles A. Leas, who, judged by his detailed 
 reports and his recommendations, was an engineer of ability. His report of 
 1853 is the first from which it is possible to form any accurate idea of the 
 amount of work done and of how it was accomplished. In the last nine months 
 of this year there were removed 43,576 cartloads of street sweepings at a net 
 cost, after the sale of the manure, of 14.5 cents a load, and 21,642 loads of 
 garbage at a cost of 43.5 cents a load. The total actual cost to the city, exclusive 
 of sweeping the streets, of the removal of 65,218 loads was $16,586.19. There 
 were 26 carts to remove garbage from 30,000 houses; i. e., each cart had to 
 collect from 1,154 houses, daily in summer and biweekly in winter. 
 
 Mr. Leas proposed a permanent garbage-disposal place on a farm owned 
 by the city, which would be served by boats and where the garbage would be 
 fed to pigs. This piggery, he thought, would in a few years yield a return 
 sufficient to pay all the expenses of garbage removal. Unfortunately his plan 
 was not adopted. 
 
 A decided step forward was taken in 1876, when householders were required 
 by ordinance to keep garbage and ashes separate, in order that the latter might 
 be used to fill in low places within the city. The garbage and other offal 
 were hauled to convenient lots near the outskirts of the city and placed on 
 large dumps until 1877, when a new policy was adopted of delivering it to 
 contractors, who removed it by rail or by barge to points not less than 6 
 miles from the city limits. This change of method of removal was forced on 
 the city by threats of suits on the part of the inhabitants of Baltimore County. 
 
 In 1880, 26,252 loads of garbage were delivered at the contractors’ dumps 
 at Canton and Spring Gardens, and for transporting this the contractors were 
 paid 51.5 cents a load. 
 
 Between 1904 and 1919, the garbage so conveyed was “ reduced ” by con¬ 
 tractors, and in the latter year arrangements were made with a contractor to 
 feed the garbage to pigs at a farm fitted for this purpose on the water-front 
 well below the city. Thus after 66 years, Commissioner Leas’s plan of garbage 
 disposal, somewhat modified, was adopted. 
 
PUBLIC HEALTH ADMINISTRATION OF BALTIMORE 
 
 119 
 
 In 1917, the number of cubic yards of garbage hauled by the city was 
 113,162; of ashes and refuse, 425,307; of street dirt, 225,224; of sewer and 
 inlet dirt, 13,760; and of snow and ice, 136,542; a total of 913,995. Dead 
 animals removed numbered 20,178. 
 
 The work in connection with the control of mosquitoes is set forth in table 4. 
 
 Table 4. 
 
 House inspections . 114,414 
 
 Breeding-places found and de¬ 
 stroyed . 3,984 
 
 Circulars distributed . 115,717 
 
 Notices sent out. 5,259 
 
 House inspectors, daily average... 26 
 
 Men employed, weekly average... 285 
 
 Pools drained. 143 
 
 Old ditches cleaned, graded, filled, 
 
 or oiled, feet.1,144,595 
 
 New ditches constructed, feet.... 16,133 
 
 Toilets reported overflowing or in 
 
 need of attention. 2,220 
 
 Complaint cards turned in bj' em¬ 
 ployees . 324 
 
 Premises and other unsanitary con¬ 
 ditions reported to city depart¬ 
 ments . 3,439 
 
 Improper garbage cans reported to 
 
 police department . 6,337 
 
 Gallons of larvacide solution used. 5,855 
 
 Gallons of oil solution used. 7,176 
 
 Gallons of kreso used. 50 
 
 The total expenditure of the department for 1917 was $876,093.02, including 
 $25,897.73 spent on the work of mosquito control. From the sale of refuse, 
 $12,729.10 were realized. 
 
 SEWERAGE. 
 
 Sewerage will be considered under three headings: First, storm-water; 
 second, household water, that is, toilet, wash, and kitchen waste; third, human 
 and animal excreta, slaughter-house waste and other wastes exclusive of garbage. 
 
 Until 1915, storm-water and household water were disposed of in the same 
 way, that is, by natural flow into the water-courses traversing the city and 
 ultimately into the harbor, basin, and the middle branch of the Patapsco River. 
 As the city grew and made a large area, which, on account of the houses and 
 street pavements, was impervious to water, the storm-water thus to be disposed 
 of very greatly increased in volume. As a result, the low-lying sections of the 
 city, particularly the narrow valleys, were often flooded, and with the subsidence 
 of the water they were left covered with a large amount of silt and street and 
 household washings, including manure, grease, and garbage. The large rain¬ 
 fall served to keep the higher and hilly sections fairly clean and took much of 
 their dirt to the low-lying portions. For the same reasons, the water-courses, 
 often in a state of flood, would overflow their banks and further add to the 
 filth in the lower, flat portions of the city. The land-locked basin, the harbor, 
 and Spring Gardens, to a lesser extent, thus in the course of time became 
 loaded with organic waste, the putrefaction of which in warm weather gave 
 rise to very offensive odors which were a constant source of annoyance. The 
 same streams, first at their mouths and later throughout their courses within 
 the city, became foul, ill-smelling sewers, giving off offensive gases in hot 
 weather. Of these, the foulest were Jones Falls and Harford Run. The storm¬ 
 water gutters in the streets and alleys, being rough and irregular and often 
 improperly graded in many places, formed pools of water containing organic 
 material. These were particularly offensive in the narrow courts and alleys of 
 the poorer sections, from which drained every conceivable kind of organic 
 waste and other filth. In 1850 there were about 2 miles of storm-water sewers 
 in the whole city. 
 
120 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 The first serious consideration of the sewerage question on the part of the city 
 government was in 1859, when a sewerage commission of three, under the chair¬ 
 manship of Henry Tyson, was appointed. In its report made in 1862, the com¬ 
 mission recommended the establishment of eight sewerage districts in which 
 sewers were to be built to carry off storm-w T ater and household waste-water, 
 exclusive of human excreta, more readily along the natural drainage lines. 
 The commission pointed out that in building the sewers then existing in 
 Baltimore, no particular form or system of size had been adopted and that in 
 but few instances could they be exactly located. They often ran a winding 
 course, the bottoms were nearly always flat; some were floored with plank 
 which had decayed and left the original earth bottom protected from washings 
 only by the accumulation of stone and other heavy substances which had washed 
 into them. Some sewers were roughly paved with stone; in all of them the 
 free flow of water was greatly impeded; and during dry weather the surface- 
 water and house drainage, spread irregularly over the surface, w T ere either 
 absorbed by the earth or evaporated, leaving heavy animal and vegetable sub¬ 
 stances to decay in the sewers, resulting in offensive effluvia arising from the 
 open and untrapped inlets. In some of the sewers, side walls only had been 
 built to confine the water course, and they were planked over at the street 
 crossings; otherwise, the floors of the houses built over them formed their sole 
 covering. The commission recommended the building of a series of sewers with 
 well constructed and trapped inlets to carry off the house drainage and surface- 
 water from the eight districts above mentioned, and planned to lead the 
 tributary sewers or laterals either into the main water-courses which were to 
 be covered over eventually or through covered sewers directly into the harbor 
 and basin. As this drainage was to go into the harbor and basin, they thought 
 it unwise to include human waste. This they planned to dispose of into the 
 ground in cesspools as before. These recommendations were carried out in 
 part somewhat slowly, and largely under the pressure of the health department 
 for the abatement of nuisances. Harford Run was not covered over until 1885, 
 and Jones Falls was covered over through a part of its course in 1912. 
 
 Mr. C. H. Latrobe, C. E., who had been appointed by the city council to 
 report on the best plan for sewerage disposal, rendered an interesting report 
 in August 1881. Recognizing that the subsoil had reached the limit of its 
 capacity to care for human excreta by the cesspool and privy systems, he recom¬ 
 mended a dual sewerage system; one for surface-water and rainfall, to dis¬ 
 charge as before into the middle branch of the Patapsco, the basin, and the 
 harbor, and the other for household waste and human excreta, to discharge 
 partly into the middle branch of the Patapsco and partly into the lower 
 harbor below Canton. His recommendations for sanitary sewers were entirely 
 passed over and the construction of storm-water sewers was continued along 
 the lines of the plans of the Tyson commission, somewhat modified by the 
 recommendations of Mr. Latrobe. 
 
 By 1890, owing to the great increase in the number of cesspools, many of 
 which had been connected to the old and to new storm-water sewers and drained 
 directly into the basin, harbor, and the middle branch of the Patapsco, and to 
 the fact that many of these sewers were improperly trapped, conditions had 
 become much worse. The uncovered Jones Falls was to a great degree a com¬ 
 bined storm-water and sanitary sewer, carrying so much filth that it was con- 
 
PUBLIC HEALTH ADMINISTRATION OF BALTIMORE 
 
 121 
 
 stantly necessary to dredge its lower portion for the removal of sediments of 
 organic matter. For 40 years or more the sulphuretted hydrogen gas evolved 
 from the sewers and the basin, with favorable wind conditions, reached all 
 parts of the city. Large quantities of sediment of sewer origin were each year 
 dredged from the basin and especially from between the docks and at the 
 sewer outfalls. 
 
 A second sewerage commission, under the chairmanship of Mr. Mendes 
 Cohen, was appointed in 1893 and engaged Messrs. Rudolph Hering and 
 Samuel M. Gray as consulting engineers and Mr. Kenneth Allen as assistant 
 engineer. After an exhaustive study, the commission, in its report of Septem¬ 
 ber 1897, recommended a dual sewerage system, the storm-water to be dis¬ 
 charged as recommended before, and the domestic waste, including human 
 excreta, to be disposed of by dilution into the deep waters of the Chesapeake 
 Bay, well below the city. Of the two alternative methods proposed by the 
 engineers, i. e., chemical precipitation before such discharge and the use of 
 filtration beds on land in Anne Arundel County, they objected to the former 
 as unnecessary and to the latter on account of its great expense. 
 
 The city government, fearing injury to the fishing industry, particularly on 
 account of the danger of infecting oysters with typhoid bacilli, directed further 
 investigation and a report on the best alternative plan. The commission then 
 suggested that the plan of land filtration be tried, but be restricted at first to 
 the sewerage from the low-level area, thus serving about one-third of the popula¬ 
 tion. The whole matter was then dropped, because the people refused to approve 
 a bond issue to pay the cost of the work. 
 
 In 1905, the third sewerage commission was appointed. Messrs Hering, 
 Gray, and Stearns served as a board of consulting engineers, and Mr. Calvin 
 W. Hendrick was appointed chief engineer. Mr. Hendrick and his staff designed 
 and superintended the building of a double system of sewers—surface-water and 
 sanitary—covering most of the built-up sections of the city. The surface-water 
 sewers discharge the storm-water as before. The sanitary sewers carry domestic 
 waste and human excreta to a point on Back River, to the southeast of the city, 
 where the sewerage is purified and the effluent discharged into the Bay. The 
 system was completed in 1915. Connections were started on a limited scale in 
 the fall of 1911 and practically all of the connectable buildings, over 90,000 in 
 the sewered area, had been connected by 1918. 
 
 As has been previously indicated, human waste was disposed of throughout 
 the history of Baltimore until 1915 either by privies, cesspools, or storm-water 
 sewers. As the city grew, the use of privies decreased and the cesspool became 
 the usual method. As a rule, every dwelling had its own cesspool, protected by 
 a house, situated in the back yard. In some of the larger houses there were 
 closets, situated either on back porches or within the houses, leading to cess¬ 
 pools, located either in the yards or under the cellars. At what date water was 
 introduced for flushing such closets in Baltimore is unknown, but in 1849, 
 according to Wynne, this practice obtained in a considerable number of the 
 better class dwellings. 
 
 L T nder the description of the water-supply, allusion is made to the partial 
 protection of the city springs against contamination by privies afforded by 
 the ordinances of 1817 and 1820. To what extent the specifications laid down 
 in the ordinance of 1820 for the construction of water-tight privies in the prox- 
 
122 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 imity of the city springs were later generally extended is not known. While there 
 is much evidence that many of the privy-wells or cesspools in connection with 
 the better class of houses throughout the city were well constructed and made 
 water-tight—at least when built—it was not until 1891 that an ordinance was 
 passed requiring that every privy-well or cesspool should be made water-tight. 
 The typical water-tight cesspool had walls 9 inches thick, of brick set in cement, 
 and the outside was well puddled with clay. At one time barrels or hogsheads 
 buried in the ground were used as cesspools. The common practice in certain 
 parts of the city, until forbidden by law in 1906, of connecting several houses 
 with a single cesspool was a frequent cause of overflow. Sanitary nuisances 
 from privy-wells or cesspools arose in several ways. In the first place, many 
 were not properly closed at the top and in consequence emitted disagreeable 
 odors, to which diseases were attributed, and attracted and fed flies, mosquitoes, 
 rats and other vermin. In the second place, on account of neglect or inaccessi¬ 
 bility, many were not regularly cleaned, and their contents overflowed into 
 cellars, yards, courts, alleys, and streets. In the third place, although in 1821 
 it was provided that all privies hereafter constructed on docks, wharves, or 
 made ground, and all other privies within the limits of direct taxation (built-up 
 sections) should be made water-tight, those that were not of water-tight con¬ 
 struction originally and those that were water-tight but developed breaks 
 saturated the soil and polluted the springs and wells. As the cesspools were 
 set in a stiff clay soil, much of this material made its way to the surface and 
 thus added to the nuisance from overflow. A large proportion of the cesspools 
 were constantly overflowing into cellars, streets, courts, and alleys, and created 
 a formidable nuisance. The privies and cesspools were cleaned out by night- 
 soil men, who, since 1798, were licensed and in a manner supervised by the 
 health department, but employed at the expense of the householder. This 
 material was hauled away in carts, at first to dumps outside of the city, where 
 it was sold to farmers, and later to scows at Folley’s and Winans’s wharves, 
 whence it was carried to Bush River and other creeks tributary to the harbor 
 and sold in its raw state to farmers or manufactured into poudrette to be sold 
 as fertilizer. At various times, with and without the permission of the city 
 government, cesspools were connected with the laterals of the storm-water 
 sewers. The chief engineer of the last sewerage commission estimated in 1910 
 that at that time 15,000 dwellings had been discharging in this way into the 
 basin and harbor. There are now over 90,000 houses connected, and in most 
 of the old 24 wards the privy and the cesspool have been eliminated. Thus, 
 the opportunities for fly-borne typhoid must have been greatly restricted. 
 
 Much of the sanitary sewerage of a considerable district in the northwest 
 and southwest sections of the city still finds its way into Gwynn ? s Falls, a 
 stream already polluted with sewerage before it reaches city limits. As the 
 population so served is still relatively small and the stream is large and rapid, 
 the insanitary conditions are by no means a nuisance comparable to those which 
 obtained in Jones Falls, or in Harford, Chatsworth, and Schroeder’s Runs in 
 former days. Jones Falls and its tributaries as well still receive a certain but 
 relatively small amount of sanitary drainage from outlying sections of the 
 city. The same may be said in regard to Herring Run, as it runs through the 
 northeastern part of the city. This stream is already polluted from sources 
 to the north of the city. The closely built up Highlandtown, bounding the 
 
PUBLIC HEALTH ADMINISTRATION OF BALTIMORE 
 
 123 
 
 eastern margin of the city, still retains to a large degree the old, primitive 
 method of storm-water and sanitary sewerage disposal which obtained in the 
 old city before the construction of the new sewerage systems. 
 
 In review, the storm-water, together with household, laundry, and kitchen 
 waste-water, and fluids from slaughter-houses, stables, and factories, was from 
 the beginning of the town until 1912 very inadequately drained by gutters, 
 through and over the streets, lanes, courts, and alleys, into the basin, harbor, 
 and the middle branch of the Patapsco, either directly or by means of the four 
 streams. After 1860 a considerable, but quite inadequate, number of storm¬ 
 water sewers removed some of this drainage from the streets. The storm-water 
 also carried a large amount of garbage and street dirt and manure. As the 
 flow was much impeded by the irregular and rough character of the pavements 
 of both streets and alleys, accumulations of water containing organic waste were 
 numerous. Until about 1870, practically all the human waste was received in 
 earth privies or in cesspools or privy wells. After this date a considerably 
 increasing amount of this material was discharged either by private sewers 
 or by connections with the storm-water sewers as they were constructed. By 
 1910 about 15 per cent of the whole amount was disposed of thus. 
 
 In certain sections of the city to which the new sanitary sewerage system 
 does not yet extend i. e., a portion of Locust Point, the outlying sections on 
 the western boundary of the city, some portions of the northwestern section, 
 and most of the Hampden-Woodberry district, old methods of disposal of 
 human excreta are still in vogue. In those portions of the city bordering on 
 the harbor, it is discharged directly into the basin or into the middle branch 
 of the Patapsco; in the western and northwestern sections it is disposed of 
 either into cesspools or into GwymPs Falls and thence into the middle branch 
 of the Patapsco by connections with storm-water sewers; in the Hampden- 
 Woodberry district, cesspools are still numerous, but a considerable proportion 
 of the human waste is discharged by storm water or by private sanitary 
 sewers—in some cases after crude forms of purification—leading into Jones 
 Falls and thence into the basin. Similarly, on the northeastern side of the 
 city, much of the newly developed section is without sanitary sewers and is 
 served temporarily by connections with storm-water sewers or by private 
 sanitary sewers—both discharging into Harford Bun or into Herring Bun, 
 and thence into the basin and harbor. The aggregate amount of the material 
 so discharged is not yet sufficient to give rise to disagreeable odors, and as 
 practically all the wells and springs in the old 24 wards have been eliminated, 
 this method of disposal has been no great menace to health. Some years must 
 elapse before the plans of the sewerage division to reach all these areas with 
 sanitary sewers are carried out. 
 
 Throughout the history of the city until the completion of the new sewerage 
 system, the overflowing privy and the disposal of night-soil were constant 
 nuisances. As in the annexation of 1888, so with that of 1919, the city annexed 
 a large territory, much of which is without sanitary sewers. 
 
 From the building of the first sewers to the completion of the new sewerage 
 system, the health department was charged with the sanitary supervision of 
 the sewers and was responsible for cleaning and for the removal of obstructions. 
 In recent years the care of the traps of the storm-water sewers has been a duty 
 of the street cleaning department, and the whole care of the sanitary sewers 
 
 9 
 
124 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 from the disposal plant to the lines of private property has rested with the 
 sewerage division of the city engineers* department. The jurisdiction of the 
 health department over both storm and sanitary drainage begins with the 
 private property lines and, within these, remains absolute. 
 
 WATER. 
 
 Until 1808, the water-supply of Baltimore was almost entirely of intra¬ 
 urban origin and was derived from springs and wells and perhaps, to a small 
 extent, from the creeks and runs traversing the territory from north to south 
 and emptying into the harbor, the basin, and the middle branch of the Patapsco 
 River. In all parts of the city, including Old Town and FelPs Point, natural 
 springs abounded. As the town and city grew, many of these springs became 
 no longer available, due to the encroachment of buildings. The earliest spring 
 now known to have been in general use was the Cool Spring, pictured in 
 Moale’s sketch of Baltimore Town (1752), situated near the western bank of 
 the basin. It played a large part in the life of early Baltimore, both as a 
 place of social rendezvous and a source of water for townspeople and for ships. 
 It was perhaps the same spring as the one later known as Clopper’s. Some of 
 the larger springs were reserved and improved for public use, being surrounded 
 by small parks or squares and covered with attractive “ spring-houses,” which 
 were supported by pillars and ornamented with balustrades. The most famous 
 of these were the Eastern, Western, Center, and the City Fountains. The 
 Eastern Fountain was situated near the corner of East Pratt and South Eden 
 Streets, and it was supplied with water from a local spring, probably Sterritt’s 
 Spring, purchased by the city in 1816. The tine spring-house with Ionic 
 columns was finished in 1819. The Western Fountain, situated at Charles and 
 Camden Streets, was supplied by pipes leading from Clopper*s Spring, several 
 squares distant, at the edge of the basin. The spring was purchased by the 
 city in 1816, and the fountain or spring-house was completed some years later. 
 Clopper, who had owned the spring, supplied vessels with water at a neighbor¬ 
 ing dock. As late as 1832, surplus water from this spring was led by under¬ 
 ground pipes to a wharf on Light Street. The Center Fountain, in Marsh 
 Market, furnished an abundant supply of water piped down from a spring 
 situated in the hill, near the present Center Street, in the park surrounding 
 John Eager Howard’s residence, Belvedere. It was written (2) of this spring 
 in 1832: 
 
 “ It enjoys the best reputation of all the fountains. As it springs from the base of a 
 hill in a neighborhood in which there are few dwellings, it is considered of less equivocal 
 origin than is occasionally imputed to the other three; and inasmuch as the virtues 
 of filtering water are not possessed by the soil of Baltimore—at least in the public 
 estimation—the Center Fountain, which requires no purification, is the most esteemed 
 by the water drinkers of this day.” 
 
 The City Fountain, or Spring House, situated at or near the corner of the 
 present Calvert and Saratoga streets, was erected after the purchase of the 
 property by the city in 1808, about the time when Calvert Street was opened 
 at this point. It derived its water from several springs, which had long been 
 in use and which sprang from the sides of the hills that overhung the original 
 course of Jones Falls at this point. 
 
PUBLIC HEALTH ADMINISTRATION OF BALTIMORE 
 
 125 
 
 That the authorities were at an early date sensible of the danger of pollution 
 of public and private springs and wells is clear from the ordinances, in regard 
 to the location and construction of privies, passed in 1817, 1820, and 1821. As 
 these ordinances provided that privy-wells to be constructed in the future 
 should be water-tight and that only such old privy-wells or vaults as were on 
 docks, wharves, or in made ground, or which, in the opinion of the health 
 authorities, might corrupt the Eastern or Western Fountains, were to be of 
 this type, and as they especially exempted privies situated without the limits 
 of direct taxation—the “ precincts ”—estimated in 1816 to include 16,000 
 inhabitants, it is clear that they failed to safeguard adequately the waters of 
 springs and wells within the city. The enforcement of these ordinances was 
 doubtless responsible for diminishing, or, as on low grounds, for actually 
 eliminating some water pollution, but in general they did not cover at least 
 the greater part of the old privies. 
 
 Before this time and later there were great numbers of private and public 
 wells scattered throughout all parts of the city. Beginning in 1797, the city 
 authorities would dig a well and erect a pump anywhere on petition of eight 
 householders residing in the vicinity of the proposed pump. These wells were 
 particularly numerous in the closely built sections of Felhs Point and in that 
 part of the city west of Jones Falls and near the basin, in which places they 
 were most open to pollution both from the surface and through the soil. In 
 1798 a superintendent was appointed for each ward to see that the wells and 
 pumps were kept clean and in good repair. In 1803 two superintendents were 
 appointed to supervise the sinking of wells and the erection of pumps within 
 the city. According to Wynne, in 1849 the pump (well) water was offensive 
 to the taste and decidedly hard, and it was seldom used by those who could 
 obtain a supply from the water company; but, as will appear later, this supply 
 was then available certainly for not more than a third and probably not more 
 than a fourth of the population. 
 
 In the very nature of things this intra-urban water-supply, drawn from 
 sources necessarily contaminated with human excreta deposited in the ground 
 in cesspools or on the ground in surface privies, both nearby, became grossly 
 polluted at an early date in the history of the town and city. Between 1790 
 and 1860, with the extraordinarily rapid growth of a closely built city, con¬ 
 ditions conspired to increase the degree of this pollution. Long after a general 
 water-supply became available to most of the inhabitants, many held tenaciously 
 to springs and wells for their drinking water. Within the memory of those not 
 yet of middle age, many people, even in the wealthiest sections of the city, 
 preferred to drink water from nearby pumps, some of which enjoyed consider¬ 
 able local fame. 
 
 As early as 1792, the legislature granted permission to a fire insurance com¬ 
 pany to organize the Baltimore Water Company, with the privilege of supply¬ 
 ing water to private users, but this privilege was not exercised. In February 
 1799, the city council authorized a commission, of which the mayor was a 
 member, to contract for a public water-supply to be obtained from either 
 Gwynn’s Falls, Jones Falls, or Herring Run and distributed to the different 
 parts of the city. This came to naught, probably because authority had not 
 been first obtained from the legislature. These powers were obtained in 1800, 
 
126 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 and in 1803 the city government appointed a commission to examine creeks 
 and streams within 10 miles of the city and to select one for a copious and 
 permanent supply of “ wholesome water.” 
 
 When nothing tangible had been accomplished, owing to delays on the part 
 of the city government, a public meeting was held on April 21, 1804, at which 
 a committee of prominent citizens, including John Eager Howard, was ap¬ 
 pointed, under the chairmanship of General Samuel Smith, to organize a 
 stock company for this purpose. Apparently the motive of the organizers was 
 not profit based in any degree upon privilege, but a patriotic desire to insure 
 an ample supply of a necessity for health and for fire protection. The Balti¬ 
 more Water Company was formally organized on May 24, 1804, and on Febru¬ 
 ary 14, 1806, it was granted powers to lay pipes and to convey water under 
 and along the streets, lanes, and alleys of the city. 
 
 At FelFs Point, where the ground was low and abounded in marshes, much 
 of which had to be filled in and was therefore particularly unsuited for wells, 
 and nearby hills, from which spring-water could be conveniently drawn, were 
 lacking, the demand for an external water-supply was more insistent than in 
 that part of the city lying west of Jones Falls. In a small area there was a 
 considerable population, and here, too, owing to the fact that vessels of deep 
 draft and long voyages docked, the demand for water for ships was great at 
 FelFs Point. It is not surprising, then, that on March 26, 1804, the city gov¬ 
 ernment granted to John O’Donnell, a member of the water commission of 
 1799, and others the rights to conduct water “ through proper pipes” from 
 a “ spring near the Harford Road ” to supply themselves and tenants of houses 
 fronting on Market Space and neighboring wharves and appropriated a piece of 
 ground on the market space for a reservoir, nor that in 1808, Joseph and James 
 Biays sought and obtained the rights to convey water by pipes under the 
 streets, lanes, and alleys of FelFs Point. How far these projects were carried 
 is not certain, but it is probable that they were merged into those of the 
 Baltimore Company. 
 
 After much discussion, Jones Falls, the most convenient stream, was chosen 
 as the source of supply for the Baltimore Water Company. A reservoir was 
 constructed on the high ground at the intersection of the present Cathedral 
 and Franklin Streets, a point well outside of and overlooking the young city. 
 Pumps driven by a water wheel and located near the present site of the 
 Calvert Street Station on Jones Falls, due east of the reservoir, forced water 
 into the reservoir from the common mill-race of KellaPs Dam, which supplied 
 power for the Salisbury Mill, situated near the old Belvedere Bridge. This 
 mill-dam, located just east of the site of the present Guilford Avenue Bridge, 
 was well above all city habitations, including those in Old Town, which marked 
 the highest limit of the built up section at that time. Soon after this time the 
 company erected a second pumping-station (later with steam pumps in reserve) 
 near the Belvedere Bridge, and, in 1838, constructed an additional reservoir, 
 with a capacity of 3,000,000 gallons, near the intersection of the present Chase 
 and Charles Streets. A third reservoir, the old Mount Vernon Reservoir, with 
 a capacity of 15,000,000 gallons, was built in 1846 near the present site of the 
 Pennsylvania Railroad Station on North Charles Street and was supplied 
 with water by natural flow from the dam of the Lanvale Cotton Mill, situated 
 some little distance above on Jones Falls. 
 
PUBLIC HEALTH ADMINISTRATION OF BALTIMORE 
 
 127 
 
 All the original water-mains and service-pipes were made of wood. The 
 former were of hemlock logs about 8 feet long, with bores of from to 4 
 inches in diameter. One end of each log being trimmed to the shape of a 
 spigot and the other end being bored to a bell-shape, the joints were made by 
 driving the spigoted end of one log into the bell-shaped end of its mate and 
 securing them by a wrought-iron band. The main valves were of cast iron 
 with tapering spigot ends which were driven into the wooden mains. The valves 
 were opened by lifting the valve-plugs with hooks. The service-pipes were of 
 cedar logs about 6 feet long and 6 inches in diameter, with bores of 1 inch. 
 They were connected to the mains by means of tapering ferrules of brass. 
 These log mains and service pipes have been dug up in nearly all the old 
 streets near the water-front in the Fell’s Point section, as well as in the district 
 represented by the original Baltimore Town, to the west of Jones Falls. 
 
 It is not improbable that the water, in passing through those wooden pipes, 
 w^as frequently contaminated by the seepage through cracks and joints from the 
 polluted soil in which the pipes were laid. In the report of the sewerage 
 commission for 1910 there is a photograph of some wooden water pipes “ about 
 one hundred years old, found in the sewer trench in Exeter Street, between 
 Lexington Street and Necessity Alley.” These logs, evidently belonging to 
 a very large main, were apparently not connected as in the above description, 
 which is taken from Mr. Quick, for there is no evidence of bell-shaped and 
 spigot-shaped ends. Judging from the photograph, they were probably joined 
 by metal sleeves, either fitted into the bore or sunk into the peripheral part of 
 the logs. In the nearest log in the photograph there is a large longitudinal 
 crack, extending from the lumen to the surface. It seems probable that, 
 with the varying pressure in such pipes, there was not only considerable leakage, 
 but, on occasions and under favorable conditions, seepage of polluted ground- 
 water into the water system. It is stated by Wynne, writing in 1849, that 
 after 1820 all the new mains were of iron and the new service pipes were of 
 lead. The water-mains at this time varied from 3 to 18 inches in diameter. 
 
 The new water-supply became available for household, fire, and general 
 purposes in 1808, when the population of the city was about 40,000; but, since 
 it was generally extended only into such sections as would pay interest on the 
 expenditure, the water was used by a relatively small part of the population 
 for potable purposes. As late as 1849, according to Wynne, the mains were 
 laid in only about one-half the populated portion of the city, and about 5,000 
 houses were supplied with hydrants with unlimited use of water. Since the 
 population was about 160,000 at this time and most of the houses were small— 
 the greater number being two stories high and many only one—it is evident 
 that even at this late date certainly not over one-third and probably not over 
 one-fourth of the inhabitants were furnished with this water-supply. There 
 were, however, some free hydrants paid for by the city for the use of the poor. 
 The charges for the use of water by private families were $10 per annum for 
 houses over 17 feet front, $8 per annum for houses under 17 feet front, and 
 $3 per annum extra for each bath and water closet. The daily consumption 
 of water (including 150 fire-plugs) w^as from 500,000 to 1,000,000 gallons in 
 summer and much less in winter. 
 
 In the early days this water was subject to some contamination from the 
 privies of Towson, of the few settlements about the mills on Jones Falls and 
 
128 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 its tributaries, and of the farms on the water-shed. To what degree the 
 country-side had become infected from the city is unknown, but it is probable 
 that the infection was not great before 1850. In 1851, according to T. H. 
 Buckler, from 2,000 to 3,000 people lived on this water-shed within 4 miles 
 of the city. The water was muddy, because the adjacent land was under cul¬ 
 tivation, and offensive, because of the large quantities of organic matter in the 
 shape of barnyard manure and poudrette put on the soil. 
 
 It would appear that the city government was not satisfied with the water- 
 supply, for Mr. John Randall, jr., made an official report to the city authorities 
 in 1836, in which, after a survey of all the eligible streams in the neighborhood 
 of the city, he recommended the Great Gunpowder Falls as the best source. 
 He estimated that this would furnish 65,000,000 gallons of water every 24 
 hours in the dry season. He proposed that a dam be built at Tyson’s Mills on 
 the Gunpowder River and another on Western Run, with a connecting aqueduct 
 constructed across the valley of Beaver Dam, passing to the limestone ridge 
 between Cockeysville and a point near Timonium and separating the Gunpowder 
 and the Jones Falls water-sheds. From this point the water was to be carried 
 by an aqueduct passing through this ridge and thence along the valley of Jones 
 Falls Creek to a large reservoir near the city, with an elevation of 300 feet 
 above mean tide. The matter did not go further at this time. 
 
 In 1849, Wynne described the Jones Falls water-supply as pure, sweet, and 
 soft, while T. H. Buckler, writing in 1874 (42), pictured it as muddy and 
 offensive to both taste and smell at times in the summer. Buckler, about this 
 time, urged the substitution of the Gunpowder for the Jones Falls water- 
 supply. 
 
 In 1854 the city acquired the property of the Baltimore Water Company. 
 The supply of water derived from the then existing dams on Jones Falls being 
 inadequate, the question of a choice of a new water-supply came to the fore 
 again. After a sharp discussion of the relative merits of Jones Falls and the 
 Gunpowder River as sources of a new water-supply, the contest was decided in 
 favor of tlie former. By means of a dam at Relay Station on the Northern 
 Central Railroad, an impounding reservoir was made called Lake Roland, 
 with an elevation of 220 feet above mean tide and an available capacity of 400,- 
 000,000 gallons. From this, by means of a tunnel 4 miles long, water was led 
 to two new reservoirs, one at Hampden, with a storage capacity of 50,000,000 
 gallons, and a second, the present Mount Royal, with a storage capacity of 
 30,000,000 gallons. The system was put into use in 1862. The consumption of 
 water was not over 8,000,000 gallons a day, and the daily available supply was 
 estimated at not under 20,000,000 gallons. 
 
 In 1870 the present Druid Hill Lake, in Druid Hill Park, with a storage 
 capacity of 429,000,000 gallons, was completed. The west high-service reser¬ 
 voir in Druid Hill Park, with an elevation of 320 feet above mean tide, 
 was finished 4 years later. In the 8 years between the acquirement of the 
 water-works by the city in 1854 and the coming into use of the new water- 
 supply in 1862, the contamination of the water shed must have become much 
 more serious. During the Civil War Baltimore was not only a great center 
 for the collection and distribution of Federal troops, but for large and numerous 
 military hospitals. Through the city passed great numbers of soldiers going to 
 and coming from the armies of the Potomac, West Virginia, Kentucky, and 
 
PUBLIC HEALTH ADMINISTRATION OF BALTIMORE 
 
 129 
 
 Tennessee, and to the city were sent not only the wounded, but the sick of 
 armies notoriously heavily infected with typhoid fever, diarrhoea, dysentery, 
 and malaria. It is probable that these soldiers spread these diseases by all pos¬ 
 sible means in the city and in the suburbs. 
 
 It became evident in 1872, a year of exceeding drought and consequent water 
 famine, that the water-supply would have to be reinforced. As a temporary 
 expedient, a dam was constructed at Merideth’s Ford on the Gunpowder Eiver, 
 and 5,000,000 gallons of water were pumped daily through a main over the 
 dividing ridge between the Gunpowder and Jones Falls water-sheds into the 
 channel of Eoland Eun, a tributary of Jones Falls above Lake Eoland. 
 
 In 1875 the city undertook the following extensive water-works: An im¬ 
 pounding reservoir on the Gunpowder Eiver at Loch Eaven, with a dam 300 
 feet long and 30 feet high and a storage capacity of 510,000,000 gallons; a 
 gate-house; a supply tunnel 7 miles long, leading to a receiving reservoir 
 (Lake Montebello), with a storage capacity of 500,000,000 gallons; and a 
 conduit a mile long to a gate-house at Clifton, with a 40-inch main to deliver 
 water to the general mains. The new Gunpowder water-supply came into use 
 September 26, 1881. 
 
 An additional storage-lake at Clifton Park, with a capacity of 265,000,000 
 gallons, was put into use in 1888. 
 
 Between 1881 and 1915, under ordinary conditions, seven-eighths of the 
 general water-supply was derived from the Gunpowder Eiver and one-eighth, 
 from the old Lake Eoland-Jones Falls system. However, until 1885, a small 
 area in the southwestern part of the city was supplied by the Baltimore County 
 Electric and Water Company. 
 
 In the 20-year period between 1862 and 1881, during which the city had 
 enormously augmented and extended the service of the extra-urban water- 
 supply, an ever-increasing proportion of the population must have voluntarily 
 abandoned the internal sources derived from springs and wells. It was not 
 until 1876 that any serious effort was made by the health authorities to have 
 the use of well and spring waters abandoned. In that year, after a very fatal 
 outbreak at Fell’s Point of so-called typho-malarial fever (which was, however, 
 yellow fever), Health Commissioner Stewart employed Professor William P. 
 Tonry to make chemical analyses of the water of certain wells in this locality. 
 All of the wells were condemned on account of the high content of chlorine and 
 organic matter. On the basis of this report and the fact that the subsoil of 
 Baltimore, for at least 10 of the total of 17 square miles, was contaminated 
 from privies and cesspools, the commissioner of health concluded that all 
 the wells and springs within the city must of necessity be polluted or subject 
 to pollution. He therefore urged that they be closed and city water substituted. 
 
 Professor Tonry examined 84 samples of water from wells and springs in 
 the city in 1879. He condemned 74 of these as contaminated. Many were in 
 close proximity to privies or to cesspools. Waters from 11 wells contained a 
 larger percentage of free ammonia than a mixture of distilled water and urine, 
 one-tenth part of which was urine. The next year, the commissioner of health 
 recommended the closing of all wells and springs within the city limits. 
 
 In 1885, Dr. Steuart, in his report as commissioner of health, gave a table 
 showing the location of the wells within the city, so far as reported to the 
 department. It was known that there were 219 abandoned wells, and that 49 
 
130 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 dug and 13 artesian wells were still employed. He estimated that at least 100 
 dug wells were in use. The majority of the 49 reported were in the most 
 crowded sections of the city. In this year, Professor Tonry condemned 12 springs 
 as contaminated. The first investigations into the general water-supply were 
 made during this year. Of four samples of the Gunpowder supply, from the 
 gate-house at Loch Eaven and tributary streams, three were classed as bad. One 
 sample of this supply, taken at Lake Montebello, was suspicious. All four 
 samples of the Lake Roland supply, taken from a city tap, were classed as 
 good, but samples from Druid Hill Lake and Lake Roland were marked sus¬ 
 picious. Later in the year (July) Professor Tonry found that samples of tap- 
 water from both supplies were suspicious. 
 
 With the annexation of 1888, a large territory, in some parts of which the 
 most primitive sanitary conditions obtained, was taken into the city. In much 
 of this territory the water-supply was drawn entirely from wells and springs, 
 which, according to the report of the commissioner of health, were “ without 
 exception polluted to the foulest degree. ... In one instance, in the village 
 of Woodberry, there were 15 cases of typhoid fever surrounding the locality of 
 one pump, from which these people all derived water.” 
 
 The water department rushed the laying of water-mains as rapidly as possible 
 in the more densely populated portion of this area, but for many years, 
 especially in Hampden and Woodberry, inhabited largely by mill workers, 
 wells persisted as the only or at least the main source of water-supply. In 
 fact, only in very recent years, as water mains have been gradually extended, 
 has it been practicable to close most of the wells in this annex. In the sparcely 
 settled areas at the borders of a city there must always be some wells allowed. 
 In Baltimore, as elsewhere, authorities have had difficulty in forcing some 
 people to abandon wells and springs to which they were accustomed for a central 
 water-supply, recently made available, until it could be conclusively proven that 
 the wells were polluted. As late as 1910, 71 samples were examined within the 
 year, 64.7 per cent of which were found to be polluted. Though it had long 
 been generally known that both water-sheds were grossly polluted from human 
 and animal sources, it was not until 1892 that its danger to public health was 
 recognized and official steps were taken to remedy this condition. In conse¬ 
 quence of complaints of possible pollution of the Lake Roland water-shed 
 from villages and farm-houses, some inspections were made by the health de¬ 
 partment this year, and many glaring nuisances were abated. Routine sanitary 
 inspection under a medical officer of the Lake Roland and Gunpowder water¬ 
 sheds was instituted in 1896, and in this and succeeding years many sources of 
 serious pollution were discovered and some of the worst were abated with the 
 assistance of the State Board of Health. Many of the worst sources of pollu¬ 
 tion, which can be eliminated only by building sewerage systems with disposal 
 plants for certain villages, still persist. 
 
 With the establishment of chemical and bacteriological laboratories in the 
 health department in 1896 begins the first systematic study of the general 
 water-supply. As these studies vary in scope and completeness from year to 
 year, it is not possible to present the results satisfactorily in tabular form. 
 While the tap-water was studied each year, the water from the tributary streams, 
 the impounding lakes, and storage reservoirs was not examined so routinely. 
 
PUBLIC HEALTH ADMINISTRATION OF BALTIMORE 
 
 131 
 
 For convenience in presenting the results of these examinations, the term of 
 years between 1896 and 1919 will be divided into three periods: 1896 to 1910, 
 1911 to 1915, and 1916 to 1919. 
 
 During the first period, it may be said in general that the chemical and bac¬ 
 teriological examinations of water from Jones Falls and the Gunpowder Fiver 
 and certain of their larger tributaries showed a high and constantly increasing 
 degree of pollution, as indicated by the presence of organic matter and high 
 chlorine content, high colony counts, and the frequent presence of B. coli and 
 certain other bacteria commonly present in the intestines; that this pollution 
 was evident in the storage reservoirs to a lesser degree; and that water drawn 
 from taps within the city, though often giving evidences of pollution, showed 
 a decided improvement over the reservoir water. It stands out clearly, then, 
 that the gross contamination of the water-supply at its sources was modified 
 to a considerable degree by storage in the city’s reservoirs. The reports of 
 Dr. William Royal Stokes, city bacteriologist, show that between 1896 and 1910 
 there was a steady increase in pollution of the tap-water, as judged by B. coli 
 content, from 4.5 per cent of the samples examined in 1896 to 57.3 per cent 
 in 1910. Out of 854 samples examined in the 15 years, 73.3 per cent were 
 positive for colon bacilli. Unfortunately, however, the size of the samples 
 tested was not uniform and varied from 1 to 10 c. c. at different times. The 
 average bacterial count per cubic centimeter of the 1,165 samples of tap-water 
 examined from 1896 to 1910, inclusive, was 703.7. On one occasion, Dr. Stokes 
 isolated B. typhosus from Towson Run. 
 
 These findings of Dr. Stokes were confirmed by Dr. William W. Ford (43). 
 Dr. Ford’s studies extended over the 5 years, 1906 to 1910, inclusive, and dealt 
 with the Gunpowder supply exclusively. In regard to the water drawn from 
 the laboratory tap, the colony count per cubic centimeter was usually between 
 500 and 600, sometimes as low as 300, and occasionally after heavy rains as 
 high as 1,500 or even 2,000. Fermentation tubes almost constantly gave posi¬ 
 tive presumptive tests when inoculated with 1 c. c., often with 0.1 c. c., and 
 occasionally with 0.01 c. c. samples. On further study, the fermentation was 
 shown to be due to five main types of bacteria (B. coli, B. proteus vulgaris, 
 B. cloacae, B. para-typhosus, B . fceculis alkaligenes) , of which B. coli was the 
 most constant. Dr. Ford found that the number of bacteria per cubic centi¬ 
 meter in the Gunpowder River and some of its most important tributaries 
 varied from 2,000 to 2,500 and that B. coli was present in dilutions of 0.01 or 
 even 0.001 c. c. He traced the sources of contamination in Beaver Dam and 
 Oregon and Western Runs, all of which were grossly polluted. 
 
 The second period, January 23, 1911, to September 15, 1915, is characterized 
 by partial purification of the general water-supply by the addition of calcium 
 hypochlorite constantly and alum sulphate at times. The practice was insti¬ 
 tuted upon the advice of Dr. William Royal Stokes, and carried out by the 
 engineers of the water board. The chemicals were added to the water from 
 suitably designed mixing tanks with mechanical control at the gateways of 
 the impounding reservoirs at Lake Roland and Loch Raven. The parts of 
 available chlorine per million varied at different times from 0.6 to 2.25. 
 The remarkably good effects of this treatment are illustrated by the marked 
 fall in the colony counts and in the percentage of B. coli determinations and in 
 the decrease in the mortality and morbidity rates for typhoid fever. 
 
132 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 The third period (after September 15, 1915) begins with the completion 
 of the new dam and impounding reservoir at Loch Raven on the Gunpowder 
 River and the extensive filtration plant near Lake Montebello, begun in 1911 
 under the advice of eminent engineers. Since this date the Lake Roland water- 
 supply from Jones Falls has been abandoned, except for emergencies. It was 
 used after heavy chlorinization for a few weeks in the winters of 1916 and 
 1917 while some necessary repairs were made to a tunnel. For at least two years 
 after the new water-supply came into use, examinations of tap-water, made in 
 the bacteriological laboratory of the health department, showed B. coli fre¬ 
 quently in 10-c. c. samples and not infrequently in 1-c. c. and 0.1-c. c. samples. 
 In some months over 25 per cent of the 10-c. c. samples of the tap-water were 
 positive for B. coli. The findings were often at variance with the results 
 obtained in the bacteriological laboratory of the filtration plant. During the 
 last two years (1918 and 1919), the percentage of positive B. coli determina¬ 
 tions in both laboratories was relatively low. The colony counts have been 
 correspondingly low. Intestinal organisms other than B. coli , with the excep¬ 
 tion of some spore-forming organisms, have similarly become rare. If low 
 colony counts and low percentage of B. coli mean pure water, this water-supply 
 as treated at present is reasonably safe. 
 
 When the Baltimore Water Company first took its water supply from Jones 
 Falls, this water-shed was in large degree wooded, relatively thinly settled, and 
 not extensively cultivated. Writing in 1851, Thomas H. Buckler (11) stated 
 that “ the ordinary current of Jones Falls is much smaller now than it 
 was when the water company was first established.” This he attributed to 
 the fact that the country, on both sides of the stream, had, in the process of 
 time, become more open and cultivated. Owing to the substitution of cul¬ 
 tivated fields for forests, a smaller proportion of its water was filtered through 
 the soil and a larger proportion was surface-water from cultivated fields and 
 therefore charged with organic matter and soil washings. In 1874 (43), he 
 described the formerly limpid current of Jones Falls, furnished from water¬ 
 sheds, as rendered impure by manure and poudrette. According to Buckler, the 
 Gunpowder River was at that time fed by springs on a shed which was for 
 the most part forest, or fields and meadows cultivated with burnt lime, to 
 decompose organic matter, and not with manure and poudrette. Until 1892 
 no one seems to have taken into account the serious pollution of these water¬ 
 sheds by human excreta from the privies in the numerous villages and isolated 
 private houses. Many of these village privies are still directly over or on the 
 tributary streams of both water-sheds. In fact, at the present time, many of 
 the smaller and all of the larger tributary streams serve as sewers of direct 
 discharge from villages, smaller settlements, and isolated houses and institu¬ 
 tions. Human waste from many dwellings reaches the streams indirectly by 
 pipes or by surface washings during and after rains. There are great numbers 
 of horse and cow stables and pig sties on their banks, and many stable-yards 
 and paddocks straddle the smaller streams. An incredible amount of valuable 
 organic matter is annually washed into these streams. On the Gunpowder 
 water-shed, the chief source of pollution with organic waste and intestinal bac¬ 
 teria is the stable rather than the privy, but the contamination from the latter 
 is still great, in spite of what has been accomplished of late years by the initia¬ 
 tive of private individuals, the water board, and the State Board of Health. 
 
PUBLIC HEALTH ADMINISTRATION OF BALTIMORE 
 
 133 
 
 Unless some unforseeable revolution occurs in the methods of disposal of human 
 waste, it is hopeless to expect that in any reasonable time the water from either 
 of these sheds will be safe for drinking purposes without careful treatment. 
 
 On account of the enormous amount of silt from surface washings brought 
 down from the cultivated fields by the heavy rains, the turbidity of the water 
 is often very great, and this renders clarification and purification both difficult 
 and expensive at times. 
 
 In recapitulation it may be said that until 1808 the water-supply was drawn 
 exclusively from intra-urban sources, many of which had been for years seri¬ 
 ously polluted with human and animal dejecta, with animal and vegetable 
 waste, slaughter-house waste, and garbage, and that from 1808 this supply, 
 growing more and more seriously polluted year by year, was very gradually but 
 never wholly displaced by an extra-urban supply from different sources always 
 subject to a pollution, the grade of which varied at different periods in its 
 history. 
 
 As late as 1850 at least two-thirds of the population must have obtained its 
 water-supply from the heavily polluted internal sources. It was not until 1862 
 that the external water-supply became available for over half of the citizens, 
 and probably by this date, and certainly soon after it (due to conditions during 
 the Civil War), this supply had become heavily polluted. These conditions 
 were modified considerably after 1872, when Gunpowder water was to some 
 degree mixed with that of the Jones Falls water-supply, and particularly after 
 1881, when at least seven-eighths of the water derived from external sources 
 came from the Gunpowder River. The intra-urban supply was further cut down 
 by the action of the health authorities after 1876, but the annexation of 1888 
 must have equalized any gain from this. 
 
 So far as the records show, the purity of the extra-urban water-supply was 
 not suspected by the city authorities until 1892. From this time on, evidence 
 of serious contamination was clear enough to the health authorities, who, 
 relatively speaking, viewed the situation from a coigne of vantage; but the 
 evidence as expressed in terms of typhoid-fever incidence and death-rates was 
 not sufficiently strong to convince the mass of the inhabitants and the rest of 
 the city government until 1910. Had the typhoid rates been marked higher, 
 purification of the water-supply would have been undertaken earlier. 
 
 Why were not these rates higher? In the first place, the water-sheds were 
 large, the cases of typhoid fever on them w^ere probably never excessive, and the 
 large impounding and storage reservoirs must have been very considerable 
 factors of safety. As will be seen later, there were other factors in the spread of 
 typhoid infection, which, taken together, were probably fully as important as 
 water. It is of interest that, so far as can be judged by the published records of 
 the Health Department, typhoid fever, until the last few j^ears, is the only 
 disease attributed to water. 
 
 FOODS. 
 
 Since the ordinances of 1797 and 1805, the city has exercised some sort of 
 supervision and control over foods, but, so far as can be ascertained from the 
 records, it was not until after the ordinance of 1894 that this activity rose 
 beyond desultory attempts on the part of the market clerks, the police, and the 
 health authorities to condemn and prevent the sale of obviously decayed meats, 
 fish, vegetables, milk, and milk products. The purpose behind the laws of 
 
134 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 179? was to guard against the importation of putrescent organic material, wliicli 
 was considered dangerous in itself, and to prevent the shipping from the port 
 of damaged foods which might injure the trade reputation of the city, rather 
 than to protect the inhabitants from foods dangerous to health. Similarly, 
 the market law of 1805 and the milk law of 1855 were probably designed to 
 protect the purses of the poor against unscrupulous dealers, rather than the 
 public health by preventing the sale of foods apt to cause disease. While in the 
 reports of the health department mention is frequently found to the nuisances 
 in and about slaughter-houses, there are no references until after 1890 to the 
 possibility of danger to the public health from the meat of diseased animals. 
 The State Live Stock Sanitary Board, created by act of legislature in 1888, was 
 intended primarily to protect the live-stock interests of the State through the 
 prevention and control of diseases destructive to animals, such as hog cholera, 
 tuberculosis, pleuro-pneumonia of cattle, trichinosis, anthrax, glanders, hydro¬ 
 phobia, and the like, and in the administration of this law and its amendments 
 the activities of this board appear to have exerted until 1916 at most only an 
 indirect and secondary influence in the protection of the Baltimore population 
 against such of these diseases as are common to both man and the domestic 
 animals. 
 
 The city ordinances of 1894 and 1904 in regard to foods were directed par¬ 
 ticularly to the protection of milk, but in connection with milk, they made it 
 mandatory for the commissioner of health to inspect meat, fish, and vegetables, 
 to collect samples of milk and all other food products for analysis by chemical 
 and microscopic methods, and to make regulations governing them. But with 
 a single chemist and three inspectors appointed in 1894, anything approaching 
 adequate supervision was impossible. Two inspectors were assigned to milk 
 inspection and one to meat. It was not until 1912, when the laboratory and 
 inspection forces were considerably expanded, that other activities were under¬ 
 taken. 
 
 During its early history and until the development of the western packing 
 industry, practically all the fresh and cured meats used in Baltimore were from 
 animals raised in Maryland or in the neighboring States, and most of it was 
 slaughtered in or near the city. At the present time this is true for a large but 
 diminishing proportion of the beef, mutton, veal, and pork. There was no ante- 
 mortem inspection of this moiety until after 1888, and during much of the time 
 since this date any such inspection has been incomplete, to say the least. Since 
 the inauguration of a meat-inspection system about 1900 by the United States 
 Government under the interstate commerce act, meat sold in Baltimore from 
 animals slaughtered in other States and in Baltimore by slaughterers engaged 
 in interstate commerce has, of course, been submitted to careful inspection. 
 The remaining large, but not exactly known, proportion of the meats sold in 
 Baltimore was submitted to no post-mortem inspection until 1912. As this in¬ 
 spection system is conducted by a single individual, a former butcher, and as the 
 slaughtering is carried on simultaneously at a large number of widely separated 
 establishments, it is evident that this inspection, as judged by accepted stand¬ 
 ards, is hopelessly inadequate, both in regard to oversight and expert diagnosis. 
 The single inspector can not begin to cover the field. According to standards 
 generally accepted, this system is reprehensibly inadequate, and, if known, 
 would be condemned severely by a large element of the public. However, after 
 
PUBLIC HEALTH ADMINISTRATION OF BALTIMORE 
 
 135 
 
 an investigation of the matter in 1915, the writer concluded not to advise the 
 city government to divert money from directions where the needs were so evi¬ 
 dently much more marked—reform in the milk-supply, for instance—to estab¬ 
 lish the traditional meat-inspection system. The evidence that lack of such a 
 system in Baltimore, under present conditions, does not appreciably jeopardize 
 the public health is very convincing. The ante-mortem inspection of live 
 animals is conducted by the State authorities, the proportion of beef and hogs 
 slaughtered outside of the United States Government inspection, both locally 
 and elsewhere, is relatively small and yearly decreasing in proportion, and, in 
 this latitude, the common diseases of calves and sheep communicable to man 
 are comparatively rare. Of greater importance, inquiry disclosed that all the 
 cuts and organs of these animals, as used by the Baltimore population, are 
 cooked before eating, and, further, that with the exception of a relatively small 
 amount of “ country sausage ” meat, all the sausage sold is boiled by the pro¬ 
 ducer before it is offered for sale. From the administrative side, due to the great 
 number of small slaughter-houses, such a system would be enormously expen¬ 
 sive for personnel or for a central abattoir into which all the slaughterers could 
 he forced. More convincing than these conditions, however, was the failure to 
 find in the health department records for '20 years previous, deaths attributed to 
 actinomycosis, glanders, anthrax, or trichinosis, diseases which, with the excep¬ 
 tion of tuberculosis, are the surest indices of danger from unguarded butchers’ 
 meat. Under the law of 1916, the board of agriculture has broad powers to 
 undertake meat inspection, but it has not yet entered this field. 
 
 There are no accurate figures on the proportion of the meats consumed in 
 Baltimore that have been submitted to United States Government inspection. 
 There never has been any systematic ante-mortem and post-mortem examina¬ 
 tion of poultry conducted by Baltimore health authorities. Much of the poultry 
 sold is slaughtered outside of the city. Since 1910, health department inspectors 
 have exercised a supervision over poultry sold by wholesale and retail dealers, 
 chiefly, as with other meats, not to search out and to prevent the sale of dis¬ 
 eased animals, but of decayed meat. Occasionally an inspector brings to the 
 laboratory a fowl with a tuberculous liver. 
 
 In 1910, health department inspectors succeeded to the supervision for¬ 
 merly exercised by the market clerks, the police, and others over the sale of 
 spoiled fish, crabs, oysters, and other shellfish. Since the State Board of Health 
 and the oyster commission began in 1915 to supervise the oyster industry in 
 the Chesapeake Bay and its tributaries and practically broke up the custom 
 of “ fattening 99 oysters at sewer outfalls and in streams known to be heavily 
 contaminated, the danger of transmission of typhoid fever and other water¬ 
 borne intestinal affections by this means has greatly diminished. The great 
 oyster-beds have probably never been exposed to serious contamination, and the 
 majority of the typhoid-fever deaths since 1880 and of the cases since 1900 
 (the date from which case reporting has been sufficiently accurate for com¬ 
 parison) have fallen in the hot months (July, August, September, and Oc¬ 
 tober), when oysters either are not eaten at all or only sparingly raw. 
 
 Until recent years, practically all vegetables and much of the fruit eaten 
 raw have come from neighboring counties, and much of both from areas 
 manured with night-soil from Baltimore, used either raw or as poudrette. To 
 what degree the bacteria causing intestinal infection originally deposited in 
 
136 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 this night-soil were killed, overgrown, and smothered by the putrefactive bac¬ 
 teria, or destroyed by drying in the process of manufacturing poudrette, or 
 killed by the rays of the sun and by drying on the surface of the soil is 
 unknown, but it is improbable that many survived to return to the city to 
 spread disease in connection with vegetables and fruits eaten raw. It is not 
 unlikely, however, that the dysentery amoeba, a protozoan organism, part of 
 whose life-history is characterized by the formation of cysts, may survive con¬ 
 ditions fatal to its bacterial neighbors, and that amoebic dysentery, when this 
 disease was an important factor in Baltimore, may have been thus spread. 
 Perhaps a more important source of infection for the intestinal diseases was 
 the water of polluted wells, springs, and streams with which fruits and vege¬ 
 tables were washed in the country; and the micro-organisms in the city night- 
 soil capable of causing intestinal disease, probably not infrequently, when by 
 chance the conditions of dilution and aeration were favorable to their viability, 
 infected the sources of the farmers 5 w r ater-supply. It is quite possible, too, 
 that such vegetables as watercress, plucked at the margin of branches and 
 creeks polluted with privy drainage and subject to overflow, have not infre¬ 
 quently served as vehicles for the conveyance of the intestinal diseases, par¬ 
 ticularly typhoid fever. 
 
 The milk-supply of Baltimore in the early days was derived from cows kept 
 in stables and on lots in the city and from dairies on farms in the immediate 
 suburbs. With the growth of the city and the development of railroads, the 
 area from which the extra-urban supply was derived gradually expanded until 
 it embraced the counties to the north, west, and east, up to the area beyond the 
 Pennsylvania border. The dairies of the southern and southwestern territory 
 of Maryland are tributary to Washington, and but little milk comes to Balti¬ 
 more from the tidewater counties, whose direct connection is by water only. 
 
 The milk ordinances of 1855 and 1879, intended to prevent fraud by adultera¬ 
 tion, accomplished nothing. No machinery and personnel for their enforce¬ 
 ment were provided. The earliest note on the Baltimore milk-supply is that of 
 Commissioner Benson, who recorded in 1872 that there were in the city 1,603 
 cows in 485 stables, with an average of 344 square feet to each stable or 104 
 square feet to each cow, which he regarded as very satisfactory and as evidence 
 that Baltimore milk must be of the first quality. The first real investigation of 
 the Baltimore milk-supply was that of Professor William B. Tonry, made at 
 the instance of the commissioner of health in 1873, in conducting which he used 
 the approved methods of that day to determine the reaction, the specific gravity, 
 and the percentages of cream by volume, the total solids, water, butter fat, milk 
 sugar, casein, and salts, and the presence of blood and pus. As a result of the 
 examination of 13 samples of milk purchased in the city, he concluded that 
 the best milk was that obtained from “ dry-fed 55 cows in good city stables; 
 next stood farm milk brought by railroad, and last was rated milk from badly 
 stabled, sickly, slop-fed cows within the city. The best city milk contained not 
 over 3.3 per cent butter fat; the country milk, on the other hand, contained over 
 4 per cent butter fat and 13-J per cent total solids. The milk of the slop-fed 
 cows was invariably acid, and it contained a high percentage of water and a 
 very low butter-fat content. Professor Tonry, as city chemist, reported in 1894 
 that of the estimated 6,658, 100 gallons sold in Baltimore in that year, 827,450 
 gallons came from cows within the city limits. 
 
PUBLIC HEALTH ADMINISTRATION OF BALTIMORE 
 
 137 
 
 Milk inspection was conducted at six railroad stations, in delivery wagons 
 which supplied households, and also in stores. Milk below the standard set by 
 the ordinance (specific gravity, 1.029; total solids, 12 per cent; butter fat, 3 
 per cent) was spilled on the street. Of 288 samples of milk of which complete 
 chemical examinations were made, 145 were watered, 69 skimmed, 23 were both 
 watered and skimmed, 29 were colored artificially, and 5 had cream and 3 had 
 preservatives added. Of 68 samples submitted to microscopic examination, only 
 4 were found clean. The picture of Baltimore milk of that date is made more 
 complete by the following items culled from the report of Professor Tonry for 
 the next year. He relates that a city dairyman, after giving a sponge bath to 
 his child ill with typhoid fever, went directly to his milking and then placed 
 five uncovered milk cans of fresh milk within 15 feet of the sick child. In the 
 cellar of a city milk and poultry dealer, chickens were found perched on the 
 rims of open cans filled with milk. Among the foreign matter found in milk 
 as received at the railroad stations, blood, live frogs, dead mice, leaves, and 
 decomposing vegetables are mentioned. Of the 1,368 cows in the city, 776 were 
 in the old, closely built sections, most of them in ill-ventilated, filthy stables, in 
 many of which were the family privies or water closets, and most of those ani¬ 
 mals were fed brewers’ grains, garbage, slops, and decomposing tomato rinds. 
 Over 1,000,000 gallons of milk sold this year 'were estimated to come from such 
 cows. Dr. Tonry strongly advised condemning the whole lot. Nearly all the 
 milk was sold from churns in delivery wagons on the street or at small groceries, 
 where it was dipped from the cans as needed. Two inspectors examined 23,763 
 lots of milk, covering 132,646 gallons out of the estimated 7,500,000 gallons 
 sold. An epidemic of 12 cases of typhoid fever was traced to milk. 
 
 The response to these revelations was prompt, and in 1896 was passed the 
 first ordinance giving the health department control of milk dealers, cows, and 
 cow stables within the city. Of especial importance were its provisions requir¬ 
 ing prompt reporting of the occurrence of “ contagious and infectious diseases ” 
 among milch cattle and in the households of dairymen and milk dealers and 
 giving the health department powers to control the use and sale of milk from 
 premises harboring such diseases. The improvement in the milk-supply was 
 immediate, for the report of the chemist for this year showed a marked fall in 
 the percentage of milk condemned for watering and skimming, and for dirt. 
 Of 40 samples of country milk, the average fat-content was 4.13 per cent (high¬ 
 est 4.9 per cent and lowest 3.12 per cent) and the average total solids, 14.23 
 per cent (highest 16.33 per cent and lowest 12.23 per cent). The use of arti¬ 
 ficial coloring and of preservatives, and the presence of blood and pus were of 
 comparatively rare occurrence. The interference with the watering of milk with 
 polluted water must have exerted a marked influence upon the dissemination 
 of the micro-organisms of acute intestinal diseases by this food. The higher 
 standards of sanitation for cow-stables set by the ordinance of 1902, requiring 
 non-absorbent floors, with proper provisions for drainage, and more air-space 
 and range for cows, and the appointment of an inspector of cow-stables, com¬ 
 bined to make it relatively unprofitable to keep cows in closely built-up sections 
 of the city. In consequence, the worst of the city cow-stables were eliminated. 
 
 From the standpoint of adulteration, the milk-supply showed considerable 
 improvement by 1906, for, according to the report of the chemist, of the 2,209,- 
 375 gallons, or about 14 per cent of the milk consumed, tested by the inspectors, 
 
138 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 only 2,241 gallons were spilled, being either watered, churned, bloody, or in 
 filthy condition. The butter-fat percentage of the 1,610 samples submitted to 
 analysis exceeded the legal requirement by at least from 0.5 to 1 per cent. 
 
 The reports of the bacteriological laboratory for this and succeeding years 
 indicated the needs for supervision and regulation of a more drastic type and 
 in new directions. Bacteriological examinations of 685 samples of milk, taken 
 in every month in 1906, showed in 403 colony counts of over 500,000 per cubic 
 centimeter; of these, 89 showed between 10,000,000 and 50,000,000, and 10 
 showed over 50,000,000. B. coli were demonstrated in dilutions of 0.001 c. c. 
 in 30 per cent of the samples containing under 500,000 bacteria per cubic 
 centimeter and in 66 per cent of those containing between 500,000 and 1,000,- 
 000. The average bacterial counts per cubic centimeter of milk for the years 
 1906 to 1908 are given in table 5. 
 
 Table 5. —Bacterial content of milk. 
 
 Month. 
 
 Average bacteria. 
 
 1906. 
 
 1907. 
 
 1908. 
 
 January . 
 
 1,000,000 
 
 6,200,000 
 
 1,000,000 
 
 February . 
 
 2,070,000 
 
 3,600,000 
 
 2,200,000 
 
 March . 
 
 1,900,000 
 
 1,100,000 
 
 5,100,000 
 
 April . 
 
 930,000 
 
 2,800,000 
 
 1,100,000 
 
 May . 
 
 5,000,000 
 
 3,400,000 
 
 6,000,000 
 
 J une . 
 
 4,000,000 
 
 4,000,000 
 
 5,000,000 
 
 July . 
 
 10,000,000 
 
 5,000,000 
 
 6,000,000 
 
 August . 
 
 23,000,000 
 
 5,500,000 
 
 7,400,000 
 
 September . 
 
 15,000,000 
 
 14,500,000 
 
 3,200,000 
 
 October . 
 
 10,000,000 
 
 7,000,000 
 
 2,100,000 
 
 November . 
 
 4,100,000 
 
 4,800,000 
 
 1,500,000 
 
 December . 
 
 1,800,000 
 
 3,800,000 
 
 700,000 
 
 Average . 
 
 5,100,000 
 
 5,800,000 
 
 3,400,000 
 
 In 1908, Dr. Stokes demonstrated by cover-slip counts, microscopic examina¬ 
 tions, cultures, and animal inoculations that a considerable proportion of 739 
 samples of milk so examined showed pus cells and streptococci virulent for 
 rabbits. Of the 88 out of 179 guinea-pigs that survived one month after an 
 injection of the sediment of samples of market milk, 4.5 per cent showed 
 typical tubercles. 
 
 The investigations of the health department, together with the agitation for 
 purer milk carried on by the United States Department of Agriculture and 
 various State and city health departments, particularly by the Woman’s Civic 
 League and the Babies’ Milk Fund, led to the comprehensive milk ordinance 
 of 1908, under which the health department established more thorough super¬ 
 vision of the market milk by means of a permit system—a system of extra- 
 urban dairy-farm and intra-urban dairy inspection, and higher standards of 
 both quality and cleanliness. By 1913, a system of dairy-farm inspection, 
 scoring, and instruction extended to over 1,500 dairy farms, and by cooperation 
 with the State Board of Health, the department was able to shut off the milk 
 from farms with cases of communicable diseases. The maximum bacterial count 
 
PUBLIC HEALTH ADMINISTRATION OF BALTIMORE 
 
 139 
 
 for market milk was set at 500,000 per cubic centimeter. The conditions under 
 which milk was produced on many farms was deplorable, but in a few years 
 great improvement took place. Within the city milch cows were excluded from 
 the closely built-up sections and milk dealers were supervised and required to 
 meet a minimum standard of cleanliness and care in handling milk. From the 
 reports it is clear that the conditions under which milk was handled and sold 
 at this time contravened every canon of sanitary law and of common decency. 
 Only a small proportion of the over 8,000,000 gallons daily sold was bottled. 
 The provisions for washing bottles and other utensils were meager. The great 
 bulk of the milk was sold from “ churns ” or metal cans with spigots, and many 
 of these cans were rarely washed. The number of small dairies and grocery 
 stores selling milk in small quantities and dipped from cans numbered hun¬ 
 dreds. There were no facilities, or very meager and dirty ones, for refrigeration. 
 The bacterial counts of milk not only at the dairies, but at the stations, remained 
 high, and much of the milk received in the warm months registered high tem¬ 
 peratures. Between 1912 and 1915 a large number of milk dealers adopted pas¬ 
 teurization and bottling of milk, and by the latter year about 60 per cent of all 
 the milk sold was pasteurized—much of it very incompletely. As a result of 
 a series of administrative maneuvers and educational campaigns, for which the 
 officials concerned are heartily to be commended, and the cooperation of some 
 of the more conscientious dealers, the milk-supply and its control had greatly 
 improved by 1916. The goal of the health department at that time was to have 
 all the milk produced from healthy cows, handled under sanitary conditions, by 
 healthy workers, from farm to the consumer, properly pasteurized within the 
 city, and delivered in sterile containers. Owing to the very general terms of im¬ 
 portant parts of the ordinance of 1908, much of the administrative effort of the 
 officials was of necessity executed under regulations issued by the commissioner 
 of health, some of the most salutary items of which were attacked as unreason¬ 
 able by recalcitrant dealers and in consequence were held up indefinitely in 
 court. This knot was cut in 1917 by the passage of an ordinance, which, by 
 covering specifically questions immediately in view, was elastic enough to grant 
 power for the use of such alternate procedures as in the future might seem wise. 
 Under these additional powers, the health officials have been able to control 
 producers indirectly and dealers within the city directly, so as not only to im¬ 
 prove greatly the sanitary conditions under which milk is produced and sold, 
 but to establish grading of milk. The result is that many poorly equipped plants 
 and numerous dealers ignorant of milk handling have been eliminated. Table 
 6 shows the fall in the bacterial count of pasteurized milk since the law went 
 into effect in November 1917. 
 
 The improvement is greater than appears, however, for in the years immedi¬ 
 ately preceding, 40 per cent or over of the milk used was raw, and much of that 
 was served by the most illy equipped dealers. Besides the numerous epidemics 
 of typhoid fever traced to milk, there was a severe epidemic of septic sore 
 throat spread by the milk of one dairy in 1912. It may now be said that the 
 public milk-supply of Baltimore has been safe and generally within the legal 
 standard since 1919. 
 
 In the Baltimore market, milk products are relatively unimportant, with the 
 exception of butter, cheese, and ice cream; concerning the two former, because 
 
 10 
 
140 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 of the widely diverse sources of origin and great quantity and technical diffi¬ 
 culties in the way, no attempt at supervision for pathogenic micro-organisms 
 has been attempted. The investigations of the health department have shown 
 that, until the last few years, much, if not most, of the so-called ice-cream was 
 made of impure, dirty milk in cellars and stores, under conditions of filth 
 almost unbelievable. Under the inspection system developed in 1912, both the 
 sanitary conditions under which this article is manufactured and the standard 
 of purity of its ingredients have been greatly improved. Since 1917, the use 
 of only pasteurized milk and cream in ice-cream has been permitted. The one 
 saving feature, from the sanitary viewpoint, was the fact that in making the 
 ordinary ice-cream, the mixture was usually cooked. 
 
 Since 1900, the inspection of bakeries and confectioneries has been carried 
 on under the health department, and since 1912, the making and sale of bread 
 and candies has been closely supervised. 
 
 Table 6. —Levy average of numbers of bacteria per cubic centimeter in samples of 
 pasteurized milk (about 300 monthly) collected from wagons on the street. 
 
 Month. 
 
 Levy average of numbers of bacteria per cubic centimeter. 
 
 1918. 
 
 1919. 
 
 1920. 
 
 J anuary . 
 
 282,000 
 
 56,000 
 
 13,000 
 
 February . 
 
 475,000 
 
 41,000 
 
 8,300 
 
 March . 
 
 450,000 
 
 54.000 
 
 15,000 
 
 April . 
 
 650,000 
 
 52,000 
 
 11,000 
 
 May . 
 
 1.500,000 
 
 96,000 
 
 22,000 
 
 June . 
 
 1,200,000 
 
 130,000 
 
 21,000 
 
 July . 
 
 1,500,000 
 
 120,000 
 
 34,000 
 
 August . 
 
 1,700,000 
 
 110,000 
 
 42,000 
 
 September . 
 
 840,000 
 
 120,000 
 
 33,000 
 
 October . 
 
 350,000 
 
 74,000 
 
 22,000 
 
 November . 
 
 115,000 
 
 14,000 
 
 12,000 
 
 December . 
 
 71,000 
 
 27,000 
 
 12,000 
 
 Besides those foods above mentioned, analyses have been made for several 
 years in the chemical laboratory of canned vegetables, meats, and other foods 
 for impurities and the illegal use of preservatives, but in 1916 work of this 
 character was discontinued as a routine practice, to avoid duplicating similar 
 work conducted by the State Board of Health. 
 
 II. PREVENTION AND ABATEMENT OF NUISANCES ON 
 
 PRIVATE PROPERTY. 
 
 Since March 20, 1801, when the commissioners of health were granted power 
 to enter all lots, grounds, and buildings on which nuisances of any description 
 might exist, down to the present day, the prevention and abatement of nuisances 
 on private property have been among the chief activities of the department, and 
 in the exercise of no other function have the health officials been brought into 
 such intimate relations with the people. For many years this function and the 
 activities in connection with small-pox (vaccination and isolation) formed 
 almost the sole basis of such contact. In general, the necessity of the public 
 oversight of nuisances on private property has varied directly with the condition 
 
PUBLIC HEALTH ADMINISTRATION OF BALTIMORE 
 
 141 
 
 of public sanitation. The bulk of the nuisances has concerned water and 
 organic waste. Only since 1886 has cognizance been taken of nuisances caused 
 by the conditions and structure of buildings as buildings. Having accepted 
 early and retained late the doctrine that certain diseases, conveniently called 
 nuisance diseases, are caused by the putrefaction of dead organic material and 
 having observed that moisture favors this process, in the opinion of both the 
 people and the authorities, it became a principal and constant duty of the 
 Health Department to the full bent of its power, means, and personnel, to keep 
 these two things apart. To this end the department has always had, in addition 
 to its own resources, the right by law to call upon the police department, the 
 legal forces, and the magistracy of the city. The early ordinances concerning 
 coffee and hides; bark and the like on the wharves, docks, and in the basin; 
 sawdust and lumber in woodyards; offal of slaughter-houses, carrion, and gar¬ 
 bage on public and private domains; and water in cellars and yards, were all 
 directed at the prevention and control of malarial, yellow, and typhus fevers, 
 dysentery, and cholera. Later, diphtheria, typhoid fever, and other acute in¬ 
 testinal diseases were included among the diseases to be similarly fought. 
 Throughout the whole history of the health department, a large portion of its 
 activities has centered around nuisances of these types, and in the annual reports 
 of the department much space is occupied with their discussion. 
 
 STANDING WATER. 
 
 In regard to lessening the amount of standing water on private property, 
 much was accomplished. By construction, filling, and drainage, results of a 
 more or less permanent character could be obtained, but, because of the topog¬ 
 raphy of the land and the rapid growth of the city, progress was slow and 
 design was always ahead of accomplishment. The securing of dry cellars was 
 a matter of considerable difficulty in many parts of the town, due to the abun¬ 
 dance of springs and to the fact that so much of the city was built upon low- 
 lying “made ground.” In many parts of the city at the present time it is 
 necessary to drain cellars with the help of various kinds of automatic pumps or 
 cellar drainers worked by water power. A very considerable proportion of the 
 nuisances reported to the health department for correction, at the present day, 
 is due to water in cellars, defective draining of yards and alleys, broken or 
 otherwise defective rain-spouts, and leaks in roofs, all of which are correctable 
 on orders issued by the health department, calling for new construction or 
 for repair of the old. 
 
 Shortly after the discovery of the relation of mosquitoes to the spread of 
 malaria and yellow fever and at a time when these pests were common in many 
 sections of the city, the question of the appropriation of money for the control 
 of this nuisance was agitated in the city council. It was not until 1907 that 
 provision was made for the annual expenditure of $10,000 for this purpose 
 under the commissioner of health. In 1915, upon the advice of Surgeon- 
 General W. C. Gorgas, of the United States Army, the ordinance of that year 
 was passed, and an anti-mosquito campaign along lines familiar to sanitarians 
 was inaugurated under the administration of the department of street cleaning. 
 This activity has been continued with marked success, but it is only fair to point 
 out that it was not undertaken until long after malaria had practically dis¬ 
 appeared from the city. 
 
142 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 ORGANIC MATERIAL. 
 
 In the early days of the city’s history, coffee and hides were the chief imports 
 of foreign origin likely to undergo putrefaction. Since these came from hot 
 climates in wooden ships apt to leak and to have foul bilges, conditions favorable 
 to their decay often existed, and law and custom demanded their active super¬ 
 vision and their prompt removal from the city to special locations for airing 
 and drying. Great quantities of fish, shellfish, vegetable produce, and firewood 
 were unloaded on the wharves of the basin from small vessels plying in the 
 Chesapeake, and the considerable offal from these sources created nuisances to 
 be supervised by the health department. 
 
 The sawdust and other timber waste of the extensive ship-building and 
 cooperage plants, all situated in the low-lying parts of the city, near or on the 
 marshes bordering Harford Run, Jones Falls, or the basin, furnished putres- 
 cible material in quantities calling for control by burning the waste material 
 and by liming the grounds. So far did fear of the dangers from the decay of 
 wood go that it was required that all lumber and firewood be so stacked that air 
 would have access to each piece. 
 
 The health department, with the assistance of the police, has throughout the 
 history of the city undertaken to enforce ordinances and regulations concerning 
 the keeping of yards, areas, private alleys, and courts clear of dirt, rubbish, 
 and garbage, but it was not until 1916 that the use of covered metal garbage- 
 cans was enforced throughout the city. The prompt removal from private 
 domains of carrion, i. e., dead animals other than those slaughtered for food, 
 governed by stringent ordinances since 1797, was exacted of the owner until in 
 recent years. 
 
 Though, since 1797, the running at large in the streets of geese, swine, and 
 goats has been forbidden by law, these and horses, milch cattle, chickens, and 
 pigeons have been allowed on private property and have been a constant source 
 of nuisances. 
 
 There was no ordinance controlling stables for cows until 1896, and it was 
 only in 1902 that the law was sufficiently comprehensive to lessen nuisances 
 from this source to any considerable degree. The numerous horse-stables, 
 usually situated on alleys, courts, and small lots, and without manure-pits ade¬ 
 quate in either size or structure, were fruitful sources of nuisances until 1913, 
 when suitable regulations were issued by the commissioner of health and have 
 since been enforced by the police and the health officials. These regulations, 
 requiring cleanliness of stables, the placing of manure in well-covered, water¬ 
 tight pits, treatment with borax when necessary, and the emptying of the pits 
 and the removal of their contents every seven days between April and November, 
 were designed primarily to control the fly nuisance. The enforcement of these 
 regulations, together with reforms in the care and removal of garbage and in 
 the cleaning and draining of streets and alleys, has resulted in a very marked 
 decrease in the number of flies, which in earlier days swarmed in certain dis¬ 
 tricts in incredible numbers. 
 
 The greatest source of nuisance upon private property during the history of 
 the health department has been household drainage containing organic matter— 
 that is, household waste-water and human waste—which was never well con¬ 
 trolled until the completion of the dual sewage system, by the so-called sani- 
 
PUBLIC HEALTH ADMINISTRATION OF BALTIMORE 
 
 143 
 
 tary section of which disposal of these materials is now satisfactory. Until 
 this time, the household wash-water, consisting of kitchen slops aud kitchen, 
 laundry, bath, and basin wash-water, passed by open brick drains or by closed 
 drain pipes, either of wood, iron, lead, or terra cotta, to the street gutters. In 
 many cases, where these drains led from the front of the house, the connections 
 were direct, or at least over a slight gutter-like depression in the front pavement, 
 leading from the house pipe to the gutter. From the majority of the houses the 
 house drains discharged into the alley in the rear, or alongside, and the waste- 
 water followed a long and tortuous course over the rough alleys to the street 
 gutters. This system, at best, was a fruitful source of nuisance because of the 
 stoppage of drains and pipes and the accumulation of material in gutters 
 blocked with paper and other rubbish; at its worst, due to defectively paved 
 or unpaved and poorly graded gutters and alleys, larger and smaller pools of 
 putrescible fluid collected. Always unsightly and often disgusting, this material 
 caused nuisances of two types: in cold weather it froze, resulting in broken 
 pipes and drains and sheets of ice in yards, alleys, gutters, and street beds, and 
 in warm weather it gave rise to nauseous odors, drew and fed flies, and served 
 as breeding-places for mosquitoes. 
 
 Of all the functions and activities of the Baltimore Health Department, none 
 has played continuously a more important part than that of controlling nui¬ 
 sances connected with human wastes. Owing to the absence of a general system 
 of sewerage, this material was, of necessity, until within the last few years, de¬ 
 posited on the householder’s lot, either on the surface, in the crude privy, or into 
 the ground in the privy-well. The development of the laws relating to this 
 subject has been traced in the section on sewerage. 
 
 It is certain that the privy-well, privy-vault, or cesspool was in existence and 
 widely used by 1797, but the date is not known when it began to replace the 
 surface privy. It is probable that until the population of Baltimore grew rapidly 
 during the Bevolutionary War and houses were constructed in closely built-up 
 blocks instead of being separate, as is the custom of villages, the surface privy 
 was common. Under those changed conditions people w 7 ould have sought a less 
 disagreeable method for the disposal of human excrement, and the adoption 
 of the cesspool, where the nature of the ground would permit it, was natural. 
 The great trouble with the cesspool system, even when the pools or vaults were 
 w r ater-tight, was that, as with the privy, the night-soil had to be removed. 
 Constant care and oversight were necessary to have them emptied before they 
 became full. With the introduction of the w T ater-closet the filling and over¬ 
 flowing of the cesspool were more rapid and frequent. Situated either in the 
 yards or under the cellars of buildings used for dwellings or business, the over¬ 
 flowing cesspool was the most serious of all private nuisances. 
 
 Since 1801 the health authorities have had the right to supervise privies and 
 cesspools, but regular inspections were not required until 1872, when annual 
 inspection was required between June 1 and 10. Those which w r ere full or 
 likely to be full before October 1 were declared in a state of nuisance and 
 ordered to be cleaned. In 1886, the health commissioner w r as given the pow r er 
 to have privies cleaned and other nuisances abated at the expense of the owners, 
 agents, or occupiers, when they had neglected to do so, and the cleaning of 
 privies was prohibited between June and October, except in case of necessity. 
 
144 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 It was never the duty of the health department to clean privies and cesspools 
 or to remove night-soil, though it always supervised this work, which was car¬ 
 ried out by licensed night-soil men. Mr. C. E. Latrobe, C. E., estimated in 
 1881 that it cost the citizens $96,000 annually to have the contents of their 
 cesspools removed. Throughout the history of the health department the 
 reports of the commissioners call attention to the great number of nuisances due 
 to overflowing privies and cesspools and to the difficulties in the disposal of 
 night-soil. 
 
 The final disposition of the night-soil was always a vexed question. Much 
 of it was dumped with garbage on dumps, within and without the city limits, 
 and it is probable that from an early date much of it was sold directly to nearby 
 farmers for use in the raw state or as poudrette (dried night-soil mixed with 
 charcoal and gypsum). The commissioner of health in 1864 strongly recom¬ 
 mended the use of raw night-soil for manure, as in Europe and in China. It 
 is mentioned in the report for 1870, as a great reform, that three dumps for 
 night-soil and street sweepings had been established in open places in the 
 suburbs, each under the charge of a keeper who took account of the number of 
 loads received and sold. In 1880 the method was changed, and night-soil was 
 hauled by contractors to Winans^s Wharf, near the extreme southerly point of 
 the city, or to Folley’s Wharf, at the southeasterly limit, loaded on barges, and 
 towed to some one of 35 localities on Bear Creek, on Middle River, or on North 
 Point Creek, where the contents were transferred by pumps to pits or tanks, 
 whence it was purchased and removed in tight wagons by the farmers of the 
 several neighborhoods and directly applied to their fields. The heavier portion, 
 which collected at the bottom of the tanks, was applied to the surface of fields 
 owned by the contractor, where it was worked up into a compost and sold as a 
 fertilizer. There was evidence that a great deal of this material found its way 
 into Bear Creek. At this time there were 150 different firms or individuals 
 licensed as night-soil men. This method of disposal was continued until 1917, 
 when, because of the small amount of night-soil, the business ceased to be 
 remunerative. Since this date the relatively small amount of this material to 
 be disposed of has been dumped into the sanitary sewers at convenient points. 
 
 The first closets were directly over the cesspools, either in the yard, or on 
 back porches, or in a room connected with the latter. In the larger houses, 
 closets of this type were on the porches of several floors. With the development 
 of the “ water ” or “ flush ” closet, the indoor closet, usually in the bathroom, 
 became common. The earliest type of “ water ” closet in use in Baltimore was 
 the “ pan,” consisting of a bucket or pan,” which, when a lever was pulled, 
 tipped over and emptied its contents into the drain pipe leading to the cesspool 
 or sewer. It was inadequately flushed by about a gallon of water. This model 
 was in common use in 1885 and was to be found in old houses as late as 1915. 
 The long and the short “ hopper-closets,” improvements over the pan-closet, 
 were next very generally used, especially in yards. The modern flushing closet 
 came into use very slowly. 
 
 A division of plumbing, with an inspector of plumbing, was established in 
 1883 at the earnest request of the commissioner of health, who, after investi¬ 
 gations had been conducted for several years by his sanitary inspectors, reported 
 that in every household in which there had been a death from typhoid and scar¬ 
 let fevers and diphtheria there was “ defective plumbing ” or overflowing cess- 
 
PUBLIC HEALTH ADMINISTRATION OF BALTIMORE 
 
 145 
 
 pools. At this time the closet connections with the cesspools and private sewers 
 were either imperfectly trapped or untrapped, and their odors often permeated 
 houses or whole neighborhoods. It was not unnatural that a people bred to the 
 belief that such diseases as diphtheria and typhoid and typhus fevers are caused 
 by poisons in the air resulting from putrefaction should embrace and cling to 
 the sewer-gas theory of their causation. 
 
 Judging from the reports of the health department, the sewer-gas theory, 
 which was responsible for the establishment of plumbing inspection, dominated 
 the department from 1875 until 1895. It doubtless served a good purpose in 
 drawing attention to the dangers and inconveniences of the cesspool and to the 
 necessity for tight plumbing. It had the deplorable consequence of elevating 
 the scientifically uneducated plumber to a position of authority in hygiene. 
 This ascendency of plumbing is not to be blamed upon the plumber, who did 
 not invent the doctrine, which, with the mechanical inventions connected with 
 his trade, stimulated the demand for his useful work. The “ defective plumb¬ 
 ing,” to which so much disease was thought to be traced, was defective, as is 
 shown by the reports of Mr. Lee, the first plumbing inspector, not only in being 
 untrapped or improperly trapped and vented, but in structure and in location 
 as well. The sewer-gas theory of disease, imported from England and adopted 
 without reservations in the Baltimore health department, though like so many 
 theories in medicine quite without basis in fact, was made to serve the very 
 useful purpose of greatly improving plumbing. Under the regulations of the 
 commissioner of health in 1898, based upon the plumbing ordinance of 1883 
 and the system of inspection carried out, the public was gradually forced to 
 install more and better plumbing and was protected against fraud in its installa¬ 
 tion. This system was of particular help to tenants, who, on appeal to the 
 health department, could have long-standing nuisances abated. The additional 
 provisions of the building code of 1908 and the power given to the department 
 by the sewerage act to force house connections with the sanitary sewers; the 
 manner in which these have been administered by the department, and finally, 
 the development of the modern toilet, have resulted in a complete revolution of 
 the privy and closet nuisances. The supervision of the house connections and 
 construction of the plumbing systems of over 90,000 buildings between 1912 
 and 1918 was a considerable administrative feat. There remain, however, some 
 25,000 houses still dependent upon the cesspool, and in connection with a con¬ 
 siderable number of old houses in the older, crowded parts of the city, there 
 are yard toilets with “ hopper ” closets, many of which are imperfectly flushed 
 and are frequently out of order. 
 
 Some idea of the activities of the health department in the control of nui¬ 
 sances on private property may be obtained from the following summary of the 
 report for 1880: The total number of nuisances examined by sanitary inspec¬ 
 tors was 4,292. Some of the principal items were: Alleys graded, paved, or 
 repaired, 320; premises cleaned and disinfected, 246; cellars cleaned and con¬ 
 nected with sewers, 803; privies reconstructed and repaired, 862; vacant lots 
 drained or filled up, 159; drain pipes constructed and repaired, 158; yards 
 cleaned, drained, paved, and repaired, 228; slaughter-houses and packing houses 
 inspected, 33. In addition, notices and orders to remedy unsanitary conditions 
 were issued as follows: Notices issued to clean privies, 17,445; to repair yards, 
 530; to clean and bail out cellars, 560; to grade and pave alleys, 4,863; to drain 
 
146 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 and fill up lots, 287; to clean and repair water-closets, 520; to clean, drain, 
 and repair premises, 380; to clean and properly construct manure pits, 140; 
 to clean grass and weeds from lots and gutters, 560; a total of 25,285. There 
 were 18,887 permits issued to open sinks. 
 
 In contrast to the above, 73 fatal cases of infectious diseases were inquired 
 into. 
 
 In 1890 it was reported that the sanitary inspectors had examined and had 
 abated 34,138 nuisances. There were issued 14,345 notices and 43,989 permits 
 to clean privies, and 10,409,800 gallons of night-soil were removed from the 
 city by contractors. 
 
 The reports of succeeding years, until 1918, when house connections with 
 the sewerage system were completed and half the alleys were properly paved, 
 show corresponding increase in nuisance supervision and control of these types. 
 
 MANUFACTORIES. 
 
 It will be noted that section 6 of Ordinance 15 of 1797 and the provisions 
 regarding manufactories inimical to public health made in succeeding ordi¬ 
 nances were directed at the prevention of offensive odors and the accumulation 
 of organic material on the property of manufacturers or its discharge upon 
 streets and alleys or upon the properties of others, and they in no way prescribe 
 safeguards for workers in connection either with the structure, lighting, and 
 ventilation of shops and factories, or with personal contact with micro-organ¬ 
 isms, chemical poisons, or irritating particles. Those omissions are doubtless 
 due in large part to the fact that industries of these types have not been numer¬ 
 ous until recently in Baltimore. All the child-labor and factory laws are general 
 State laws passed since 1884 and are in large degree executed by State officials. 
 
 The ordinance of 1871, which provided that no slaughter or hide houses 
 should be erected within the city, has not in any marked degree decreased the 
 number of such places within the city; for, with the annexation of 1888, a 
 territory containing nearly all the slaughter-houses near the old city came 
 within the corporation. Most of these were small private slaughter-houses for 
 sheep, calves, and cattle, situated in the rear of the homes of their owners, who 
 are for the most part cleanly and thrifty market butchers, selling meats of their 
 own killing. The existence of most of these small slaughter-houses is unknown 
 to the casual passer-by, and they are but rarely the subject of complaint on 
 the part of neighbors. Frequent subject of complaint, however, are the prem¬ 
 ises of poultry slaughterers in certain sections of the city. There are a few 
 large slaughter-houses for hogs, established many years ago, in the closely 
 built-up sections of the city, convenient to the railroad tracks, but these are 
 rarely, if ever, at the present day at least, the source of nuisance. At the 
 northwest border of the city, without the city limits before 1919, are the slaugh¬ 
 ter-houses of the large packers and the stockyards and Union Abattoir. 
 
 HABITATIONS. 
 
 The laws applying to habitations passed between 1871 and 1908, in so far as 
 they relate to structure outside of plumbing, are under the administration of 
 the inspector of buildings, and in so far as they concern cleanliness and manner 
 of keep, are enforced by the health officials. 
 
PUBLIC HEALTH ADMINISTRATION OF BALTIMORE 
 
 147 
 
 With the exception of those provisions that deal with safety where dependent 
 upon strength and mode of structure, the main object of the ordinances of 1884 
 and 1908 was to set a minimum standard of light and air ventilation compatible 
 with health, to secure against dampness, and to provide adequate water and 
 toilet facilities. 
 
 The ordinance of 1884 was passed opportunely, for about that date many old 
 houses in the lower parts of the city, being vacated by their former owners or 
 tenants, were being transformed into boarding-houses or into two and three 
 family dwellings. In the larger of these there was the temptation to divide the 
 very large rooms into two or more rooms, one or two of which would be entirely 
 devoid of daylight. This law also put an end to building houses with a window¬ 
 less central room on each floor. 
 
 In 1900 there was established in the health department a division of tene¬ 
 ment-house inspection, to which were referred not only the general oversight 
 and supervision of tenements, and of lodging and boarding houses, but all 
 questions relating to nuisances therein. To this end, dwellings of these sorts 
 were placed under a system of repeated systematic inspection designed, on the 
 one hand, to force the landlords to make necessary repairs and renewals—white¬ 
 washing, painting, and the like—and, on the other hand, to require the tenants 
 to observe the rules of cleanliness. 
 
 The ordinance of 1908 was intended particularly to control the modern tene¬ 
 ment and apartment house. 
 
 III. MEASURES OF RESTRICTION, INOCULATION, AND DISIN¬ 
 FECTION DIRECTED AGAINST THE CONTAGIOUS DISEASES. 
 
 Under this heading it is proposed to give a general account of the attitude of 
 the health officials toward the control of the spread of febrile diseases, especi¬ 
 ally those regarded as contagious, by administrative measures other than the 
 control of nuisances and the order in which their control was attempted. Con¬ 
 sideration of the methods used in seeking to control particular diseases and 
 groups of diseases is reserved for later chapters. It is to be borne in mind that 
 the official attitude in regard to a given disease varied at different times. For 
 this there were many reasons, one of the most important of which being the 
 changes in the knowledge or belief in regard to its causation and mode of 
 spread. Another reason was the idea entertained of its relative importance 
 at any particular time. A third reason was lack of organization and of means 
 at all times to pursue ideas to their ultimate conclusions and thus to do thorough 
 work. From the health reports and from contemporary literature, both medical 
 and lay, and from administrative experience, the indelible impression is gotten 
 that, throughout its history, the Baltimore health department has followed a 
 vacillating course, dependent in great degree, at times certainly, on lack of 
 means and public support and often on absence of intelligent direction. For 
 these reasons its course has been one of expectant opportunism, and it has 
 rarely met facts squarely face to face. 
 
 In certain respects, its attitude has been consistent; for instance, in holding 
 that malaria and yellow fever are not contagious, and are due to conditions asso¬ 
 ciated with standing water and decaying vegetable material; that whooping- 
 cough, measles, and small-pox are caused each by a specific morbific agent spread 
 from the sick to the well by personal contact or by contact w T ith materials inti- 
 
148 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 mately associated with the sick ; and that small-pox may be prevented by vac¬ 
 cination. Yet the efforts put forth were never sufficiently adequate to test these 
 doctrines. Certain diseases, such as diphtheria and typhus fever, were tossed 
 from one category to another. Long years elapsed after it had been shown that 
 cholera and typhoid fever are commonly spread by water and after it had been 
 proven that these diseases and diphtheria and scarlet fever are often carried 
 by milk, before such knowledge was reflected in the conceptions and activities 
 of the health department. 
 
 That officials may exercise properly their function of attempting to control 
 the occurrence or spread of diseases, it is necessary in the first place that they 
 be informed promptly of the name and address of each case. For the exertion 
 of effective control, it has long been held that they must have ample power to 
 isolate the sick and those in contact with them, to disinfect and destroy clothes, 
 bedding, furniture, and even houses. In 1801, physicians were “ invited ” by 
 ordinance to report “ contagious diseases,” and the commissioners of health 
 were empowered to remove persons ill with such diseases to a hospital or other 
 place and to cut off communication with the “ affected house.” When such a 
 disease threatened to become general, they were authorized to advise the inhabi¬ 
 tants to remove to quarters provided for the purpose. From contemporary medi¬ 
 cal literature, it is certain that small-pox, typhus fever, and yellow fever, when 
 in epidemic form, were reported under the terms of this invitation, and that 
 many individuals ill with these diseases were hospitalized; that on more than 
 one occasion, on account of yellow fever, the inhabitants of Fell’s Point and 
 other infected districts followed the official advice to flee, and that many were 
 supported in camps at the city’s expense. 
 
 The ordinance of February 10, 1820, in which the health laws were revised 
 in conformity with the advice of the local medical society, contained two sig¬ 
 nificant new features—one requiring physicians to report cases of malignant, 
 pestilential, or contagious diseases, and the other requiring keepers of taverns 
 and lodging houses to report cases of illness occurring between March and 
 November among seafarers or other sojourners in their houses. This ordinance 
 was reenacted 19 days later, eliminating the section which required the report¬ 
 ing by physicians. This step was probably taken at the behest of certain promi¬ 
 nent physicians at Fell’s Point who had become disgruntled the previous year 
 because, w r hile they, themselves, had loyally reported cases of yellow fever, 
 physicians in other parts of the city, so they claimed, had neglected or refused 
 to do so. The health authorities had to remain content with voluntary reporting. 
 The provision requiring the reporting of cases of illness in taverns and lodging, 
 and boarding houses has been retained in one form or another in succeeding 
 ordinances. 
 
 The law of 1821, which empowered the commissioners of health to fence off 
 and surround by sentinels any district in which yellow fever was “ confirmed and 
 beyond control,” w r as designed rather to keep people out of such districts than 
 to prevent the exit of those living therein, because it had been decided in 1819 
 for all time in Baltimore that this disease is not contagious. It had been ob¬ 
 served, however, that it was dangerous to allow persons to expose themselves 
 to the air of the districts in which yellow fever cases have originated. It was 
 the locality and not the sick that was considered dangerous. This provision was 
 reenacted in the various revised ordinances and appears in the code of 1869. 
 
PUBLIC HEALTH ADMINISTRATION OF BALTIMORE 
 
 149 
 
 When cholera first appeared in 1832, it was officially declared to be non- 
 contagious, and the dispensaries and emergency hospitals that were established 
 were designed avowedly for the early treatment of the poor and for the better 
 care of the dangerously ill rather than for isolation. Similarly in 1866, cases 
 of cholera were reported, and though only one case (the whole number is not 
 recorded) was traced to contact with a previous case, care was taken to remove 
 and to destroy everything used by those affected with the disease and to dis¬ 
 infect and to bury the discharges of the sick, and many were removed to a 
 hospital. 
 
 There is evidence that in the early years, isolation, hospitalization, and dis¬ 
 infection were practiced in the control of typhus fever, and after 1840, many 
 cases were sent from the city to the pest-house at the Marine Hospital. In 
 1866, the commissioner of health reported that a small epidemic of typhus fever 
 was controlled by sending the sick to the hospital. However, in 1851, T. H. 
 Buckler sharply criticized the authorities for sending typhus fever patients to 
 the general wards of the almshouse infirmary. 
 
 Small-pox, the most dreaded of all the epidemic diseases in Baltimore, as 
 the reports of the health department show, was always reported (though the 
 number of cases is unfortunately not recorded for all the years) and was con¬ 
 sistently fought by vaccination, by hospitalization of the sick and isolation of 
 the exposed, and by fumigation or destruction of personal effects. In 1824, four 
 emergency vaccinators were appointed, and since 1826, the position of vaccine 
 physician has been permanent. Vaccination first instituted for the poor was 
 enforced with vigor in times of epidemics. The section of the ordinance of 
 1834, in which physicians were requested to report cases of small-pox within 
 24 hours, under threat of having the names of those who neglected or refused 
 to do so published, passed at the beginning of an epidemic, was modified in the 
 revised health ordinance of 1838 with omission of the threat. Small-pox was put 
 on a level with other diseases in the code of 1869, in which even the request to 
 report was eliminated. 
 
 There is no allusion in the health department reports to efforts at the control 
 of diphtheria, scarlet fever, measles, whooping-cough, and typhoid fever by 
 isolation, hospitalization, or otherwise, until late in the nineteenth century. 
 The prevalence of scarlet fever and measles, both in fatal form, is often men¬ 
 tioned, and as early as 1838 the consulting physician gave it as his opinion 
 that “ scarlet fever and measles occur under no fixed laws and both seem in¬ 
 clined to abide with us. r Diphtheria, scarlet fever, and typhoid fever, all 
 widely prevalent in 1875 and for a number of years thereafter, were attributed 
 to sewer gas. That diphtheria and typhoid should be considered foul-air or 
 nuisance diseases at this time is not strange, but that scarlet fever, a typical 
 exanthematous disease, considered for hundreds of years a specific contactive 
 disease, should have been included in this group, is surprising. 
 
 None of the diseases just mentioned were included, so far as the reports of 
 the health department show, among the reportable diseases until 1882, when bv 
 ordinance diphtheria and scarlet fever, together with small-pox, varioloid, 
 cholera, and yellow fever were specifically named as diseases to be reported 
 within 24 hours by physicians, and keepers of hotels and boarding and lodging 
 houses, by agents and owners of tenement houses and private houses, and by 
 the managers of institutions. The list was amplified by ordinance to include 
 
150 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 whooping-cough, mumps, and membranous croup in 1890, but it was not until 
 1895 that typhoid fever was added. Typhus fever has never been made report- 
 able in Baltimore by ordinance. Though between 1870 and 1890 the commis¬ 
 sioners of health recorded the sending of inspectors to visit the houses of indi¬ 
 viduals dead of diphtheria, or scarlet or typhoid fever, certain it is that so far 
 as management of persons is concerned, nothing was attempted during these 
 years for the control of febrile diseases except small-pox. During this period, 
 scarlet fever, measles, diphtheria, whooping-cough, and typhoid fever were not 
 only very prevalent but very fatal, as attested by comments of the commis¬ 
 sioners. The department seems to have exhausted its energies over small-pox, 
 typhus fever, and nuisances. It was not until 1890 that communicable diseases 
 were reported in considerable numbers. In that year, 2,593 cases were men¬ 
 tioned as visited by sanitary inspectors. 
 
 The commissioner of health at this time, Dr. George F. Rohe, the first who 
 had a first-hand acquaintance with pathological anatomy and parasitology, 
 revived the case-reporting and advised disinfection and fumigation of rooms 
 and houses after death or recovery from contactive diseases and recommended 
 systematic hospitalization of cases of diphtheria and scarlet fever. Dr. Rohe, 
 finding that a large proportion of the children in the public schools, though 
 possessing physicians’ certificates, had never been successfully vaccinated, 
 excluded the unvaccinated and thus laid the foundation for systematic require¬ 
 ment of vaccination of all school children as a condition precedent to admission 
 into school in Baltimore. 
 
 In 1892, the era of active and concerted attempt to restrict contactive diseases 
 other than small-pox and typhus fever may be said to have begun. The number 
 of vaccine physicians, who acted also as health wardens and to whom fell the 
 duty of establishing such isolation and quarantine in households as was at¬ 
 tempted, was doubled, one being allocated to each of the city wards, and the 
 number of sanitary inspectors was increased to 11. The sewer-gas doctrine was 
 dropped, and though attention to nuisances absorbed to a very large degree the 
 activities of the department, there are indications of a more critical considera¬ 
 tion of the natural history of the febrile diseases, resulting in a recognition that 
 certain of them may be spread in a variety of ways. As has been shown in an¬ 
 other chapter, this change was to a very great degree due to new influences that 
 had arisen in the medical profession of the city. Reports of 7,475 cases of 
 “ infectious diseases ” were received this year, many children from “ infected 
 houses ” were detected in schools, disinfection and fumigation of houses are said 
 to have been carefully done, and 12,690 articles of clothing and bedding were 
 disinfected. 
 
 By 1894, the commissioner of health had demanded a bacteriological labora¬ 
 tory for the diphtheria-culture test, provision to obtain diphtheria antitoxin 
 for free distribution, and the establishment of a special hospital for infectious 
 diseases. He was granted a chemist and three inspectors for the control of 
 food, and efforts to improve and protect the milk-supply were pushed. 
 
 The report of the commissioner of health for 1895 is remarkable in that it 
 gives the number of cases of each communicable disease reported, contains an 
 intelligent discussion of the causation of typhoid fever, with an account of a 
 milk outbreak of this disease, and recognizes that the causative agents of certain 
 diseases may be spread in several ways. 
 
rUBLIC HEALTH ADMINISTRATION OF BALTIMORE 
 
 151 
 
 The year 1896 was another turning-point in the attitude of the department 
 toward communicable diseases. It is not going too far to state that up until 
 this time everything, and indeed much more that the department had under¬ 
 taken and accomplished for the control of disease (vaccination against small¬ 
 pox excepted), could have been done just as effectively under the influence of 
 the ideas and knowledge of a hundred years before. While its previous efforts 
 doubtless had some considerable influence in restricting some diseases, care¬ 
 ful examination of all the recorded facts fails to elicit convincing evidence 
 that, so far as those diseases believed to be entirely or even mainly spread by 
 contact are concerned, the Baltimore health department had ever applied 
 Mead’s recommendations systematically and thoroughly to the control of even 
 one of them, or that any one of these diseases, even small-pox, to which it was 
 particularly attempted to apply these principles, and even with the assistance 
 of vaccination, was controlled when in epidemic form in any appreciable degree. 
 As is clearly shown from the statements of the commissioner in this year, no 
 consistent attempt had been previously made to carry out isolation, hospitaliza¬ 
 tion, and disinfection in connection with the control of these diseases under 
 legal authority possessed, since 1801. 
 
 From 1896 begins in the health department a more serious effort to apply 
 consistently old knowledge and theories, with modifications and amplifications, 
 under the stimulus of the rapidly accumulating knowledge of modern chemistry, 
 pathology, and micro-parasitology. The commissioner of health pointed out 
 that efforts to restrict infectious diseases in past years had not had the desired 
 effect, and attributed this failure to neglect by physicians to report cases; lack 
 of sufficient funds and appliances; the superficial and inadequate character of 
 the methods of disinfection employed; and the absence of a properly trained 
 corps of disinfectors, of a steam disinfecting plant, of sufficient hospital facili¬ 
 ties, and of adequate supervision of the infected. Patients were discharged from 
 isolation and quarantine under no fixed rules and on the certificate of the 
 attending physician that in his opinion danger of transmitting the disease had 
 passed. In addition to remedies for these delinquencies, he suggested a system 
 of school inspection and the inauguration of measures to prevent pulmonary tu¬ 
 berculosis. This year was further distinguished by the establishment of labora¬ 
 tories of chemistry and bacteriology, at the heads of which were well-trained 
 men. In the latter, the advantage of laboratory diagnostic methods for diph¬ 
 theria, typhoid fever, malaria, and tuberculosis were at once offered, and investi¬ 
 gations of water and milk were undertaken. 
 
 There were developed in the department, during the next few years, the 
 restrictive procedures including isolation and household quarantine, placarding, 
 supervision by health wardens, discharge certificates, culture tests, formaldehyde 
 disinfection of rooms, steam sterilization of clothes and bedding, the develop¬ 
 ment of methods to prevent the spread of diseases through milk and other foods, 
 and the like, which in the main accord with the standard practice in English 
 and American municipalities. It is remarkable that the placarding of houses 
 harboring cases of communicable diseases, with the exception of small-pox, does 
 not seem to have been practised by the Baltimore health department, until it 
 was introduced in 1898 for diphtheria by Commissioner C. Hampson Jones. 
 
 Sydenham Hospital, accommodating 40 cases of diphtheria and scarlet fever, 
 was opened in 1909, and its capacity was increased to 60 beds in 1915. 
 
152 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 In 1904, a new structure was completed at the quarantine station to receive 
 cases of small-pox and typhus fever from the city. 
 
 Since 1898, creditable studies concerning the occurrence and distribution of 
 diphtheria, scarlet fever, small-pox, typhoid fever, tuberculosis, and pneumonia 
 have been made by Dr. C. Hampson Jones and Dr. William Eoyal Stokes. 
 
 A system of medical inspection of school children was inaugurated in 1905, 
 and in 1910 a division of tuberculosis, with nurses and dispensaries, w r as 
 established. 
 
 Since the health department by 1898 was committed to the theory that the 
 spread of diseases regarded as distinctively communicated by contact from one 
 person to another is controllable by isolation of the sick and disinfection or 
 destruction of their contactive environment and deliberately set out to base 
 administrative practice upon this theory, it becomes necessary to examine both 
 the possibilities and the results as measured in actual control of these diseases. 
 The century-old plan comprehends early and complete isolation of the affected 
 and his contacts and disinfection by physical and chemical means of his con¬ 
 tactive environment. 
 
 It has been pointed out that before 1898, except in connection with small-pox 
 and, on occasion, typhus fever, the health department pursued a policy of 
 laissez-faire, most measures to this end being undertaken on the initiative of 
 the family physician or the family of the affected. With the exception of small¬ 
 pox and typhus fever (when not prevalent in excessive degree), adequate facili¬ 
 ties for hospitalization of more than the merest fraction of the total number of 
 cases of scarlet fever, diphtheria, whooping-cough, measles, epidemic meningi¬ 
 tis, poliomyelitis, typhoid fever, cholera, and pulmonary tuberculosis have never 
 been available to the health department. For these diseases, therefore, such 
 isolation as it has been possible to attempt has been confined for practicable pur¬ 
 poses to the households or institutions in which the patients were domiciled. 
 Since an overwhelming majority of families live in dwellings of not over six 
 rooms, with but one bath and toilet room, and the mother does the cooking and 
 household work, with only the help that older children or other members of 
 the family are able to give, complete isolation of the sick is manifestly impos¬ 
 sible in most homes. Since nearly all of the institutions, including orphan asy¬ 
 lums, hospitals, and the like, until the last three or four years, have lacked 
 adequate rooms and other facilities for isolating those sick of the communicable 
 diseases, those diseases which readily spread by contact when once present are 
 apt to run their courses but lightly influenced by restrictive measures. Measles, 
 whooping-cough, diphtheria, scarlet fever, mumps, and chicken-pox, the more 
 common diseases of this category and the ones which are particularly apt to be 
 transferred to others during the prodromal or incubative stages, have, therefore, 
 in the great bulk of the homes and in most institutions defied the attempts of 
 physicians and the health department to prevent their spreading to all or to 
 most of the susceptibles within their walls. As is well known, in families with the 
 largest houses and the most favorable conditions of structure and service, these 
 diseases, when introduced, commonly spread to the susceptibles at will. The 
 same is equally true of epidemic meningitis and of poliomyelitis. It is clear, 
 therefore, that, in the nature of things, the most that can be hoped for is to 
 restrict these particular diseases to the members of the household. For some 
 years the health department has permitted and even encouraged the sending of 
 
PUBLIC HEALTH ADMINISTRATION OF BALTIMORE 
 
 153 
 
 children exposed in their homes to scarlet fever, measles, and mumps to the 
 homes of relatives or friends without children, under proper restriction. As a 
 matter of fact, in the ordinary household or institution with children and 
 young adults, it is with few exceptions the rule in Baltimore, as elsewhere, for 
 measles, whooping-cough, mumps, and chicken-pox, when introduced, to attack 
 all the susceptibles either at once or in rotation, and, in the case of diphtheria, 
 for a large percentage of those exposed to develop the carrier state at least. 
 With scarlet fever, under similar circumstances, it is not uncommon for several 
 or for all of those theoretically susceptible, i. e., under 20 years of age and not 
 protected by a previous attack, to escape, even when contact with the sick has 
 been close. The same holds true usually for poliomyelitis and for epidemic 
 meningitis in ordinary years, though, in regard to the latter disease, a con¬ 
 siderable proportion of the inmates are proven by cultures to harbor the causal 
 agent. In regard to small-pox, the danger of spread within the family or insti¬ 
 tutional population is lessened in proportion to the number of inmates who 
 have previously passed through attacks of small-pox or vaccination and the 
 promptness with which vaccination and revaccination are instituted. With 
 typhus fever, too, there existed little chance of preventing spread within a 
 dwelling in which the disease appeared. In exceptionally large houses of the 
 very rich, with ample service, and in two hospitals, the Johns Hopkins Hospital 
 and the Robert Garrett Hospital, with satisfactory provisions for the purpose, 
 early separation of those sick with these affections has undoubtedly on repeated 
 occasions, but by no means invariably, been followed by failure to spread. 
 Otherwise, however, for the diseases under consideration, the sole effect possible 
 to be hoped for is the prevention of their spread to the outside population, by 
 interfering with the outgoing and ingoing of persons and the passage out of 
 materials. In connection with typhoid fever, until the last few years, no 
 measures of isolation of the sick or of protection of those exposed were pre¬ 
 scribed either in homes, hospitals, or other institutions. No isolation of cases of 
 pulmonary or other forms of tuberculosis within homes and institutions has ever 
 been advocated by the Baltimore Health Department, and no restriction (except 
 to forbid the handling of food for sale) has been put upon the free movements 
 of those with open tuberculous lesions. Disinfection of sputum has not been 
 required. Since 1905, under the State law, fumigation with formaldehyde gas 
 of the rooms occupied by registered cases of pulmonary tuberculosis has been 
 carried out after death or removal for other cause. 
 
 In the early days, houses harboring cases of small-pox and typhus fever were 
 posted with warning signs, and even guards were often placed to prevent ingress 
 and egress. These signs were first posted on premises on which were cases of 
 diphtheria in 1898, and the use of similar signs was instituted for scarlet fever, 
 measles, whooping-cough, chicken-pox, mumps, epidemic meningitis, and poli¬ 
 omyelitis in later years. As late as 1915 this was done, except in cases of diph¬ 
 theria and scarlet fever, with no regularity. 
 
 Small-pox is the only disease for which the health department has consis¬ 
 tently practiced removal to hospitals, but in times of considerable epidemics 
 facilities were not at hand to hospitalize half the cases discovered. Cases of 
 typhus fever, during the great prevalence of the disease in the first three 
 quarters of the nineteenth century, were sent to the department’s hospitals in 
 large numbers, but apparently more for the better care of the destitute sick than 
 
154 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 as a method of disease restriction, for cases were often sent to the open wards 
 of the almshouse infirmary. Since 1900 at least, the rare cases of typhus fever 
 have been hospitalized primarily as a protection to the rest of the community. 
 The relatively small number of beds in the Sydenham Hospital has been ade¬ 
 quate to accommodate so small a proportion of the cases of diphtheria, scarlet 
 fever, or measles, occurring within the city, that its use has practically been 
 limited to the care of severe cases of these diseases happening under home con¬ 
 ditions particularly unfavorable for treatment. As an isolation hospital in the 
 true sense of the term, it can not for these diseases be said to exist. It has very 
 occasionally been used in this sense for cases of poliomyelitis and epidemic men¬ 
 ingitis. Compulsory hospitalization, except very occasionally, lias never been 
 practiced in Baltimore for cases of typhoid fever. 
 
 It has been shown that the system of school inspection practiced could not 
 by any chance be credited with any material effect in the control of any com¬ 
 municable diseases, except in so far as it assured the enforcement of vaccination 
 and has assisted in the gradual delousing of the population. 
 
 That warning signs have exercised a helpful effect in keeping the more 
 enlightened part of the community from contact with cases of communicable 
 diseases is certain, but it is no less certain that they have had no restraining 
 influence upon a considerable section of the population. The same may be said 
 concerning restrictions sought to be imposed upon the inmates of houses harbor¬ 
 ing communicable diseases from mingling with the neighbors and the public. 
 If the neighbors are in sympathy, they mingle freely; if they are opposed, 
 whether on account of fear or wish to support the law and the authorities, the 
 offenders are reported, and actions are taken by the department to enforce its 
 regulations. It is probable that in some degree more or less serious, the regu¬ 
 lations of the health department in regard to household quarantine are broken 
 in at least the majority of instances. 
 
 From the beginning, the discharge of patients and contacts from isolation 
 in the case of small-pox and typhus fever has been rather rigidly supervised and 
 controlled by the health department. For other diseases, the discharge was at 
 the discretion of the physician in charge until 1898, when the health depart¬ 
 ment assumed entire charge of the matter through the health wardens. Since 
 1898, the health warden’s certificate has been required of children and teachers 
 returning to school after isolation for small-pox, typhus fever, diphtheria, scar¬ 
 let fever, measles, mumps, chicken-pox, and whooping-cough. In 1917, epidemic 
 meningitis and poliomyelitis were added to this list. The discharge of cases of 
 diphtheria and of diphtheria carriers since 1896 and of cases of epidemic men¬ 
 ingitis and meningo-coccus carriers since 1917 has been controlled by culture 
 tests. In regard to all other diseases, the date of discharge of the recovered and 
 of contacts has been governed in the case of the former by arbitrary and varying 
 standards, and in the case of the latter by the average length of the incubation 
 period. Since 1916, typhoid carriers have been forbidden to prepare or other¬ 
 wise handle food for others. 
 
 The Baltimore health department has never inaugurated a single administra¬ 
 tive measure directed at the control of the venereal diseases. Under the regu¬ 
 lations of the State Department of Health of 1894, applying to the whole State, 
 cases of ophthalmia of the newborn, commonly gonorrhoeal in origin, have been 
 reported, and the department has been active in enforcing prompt treatment, 
 but entirely from the standpoint of restricting blindness. In regard to the 
 
PUBLIC HEALTH ADMINISTRATION OF BALTIMORE 
 
 155 
 
 venereal diseases in their usual forms, from either the standpoint of prevention 
 or cure, it has never inaugurated a single activity. An ordinance designed to 
 prevent promiscuous sexual intercourse in boarding and lodging houses, apart¬ 
 ments, and hotels was passed in 1918 at the insistence of the United States 
 army officials. Since venereal diseases were made reportable by resolution of 
 the State Board of Health the same year, the Baltimore health department 
 has contented itself with receiving such reports as were made and with lend¬ 
 ing its power, when called upon, to force a few recalcitrant patients to appear 
 at the venereal-disease clinic established by the United States Government in 
 cooperation with the State Board of Health and at the clinic of the Johns 
 Hopkins Hospital. No effort was made to establish clinics in the department, 
 to enforce the reporting of cases, or to establish any machinery for their over¬ 
 sight. Since 1896, the bacteriological laboratory has examined cover-slip 
 preparations for gono-cocci, and since 1916 it has made Wassermann reaction 
 tests for physicians. 
 
 The removal of materials from dwellings and institutions harboring cases 
 of communicable diseases, though probably forbidden by the health depart¬ 
 ment, was not controlled with any certainty until recent years. Since milk has 
 been delivered in bottles, and before 1910 certainly no large proportion of 
 household milk was so delivered, the health department has seen to it that empty 
 milk bottles from “ infected 99 households have not been removed by milk dealers 
 until disinfected under its supervision. Effective restriction on the sending of 
 laundry to washwomen is not possible, but, with the extensive development of 
 public laundries during the last 25 years, on account of the cooperation of these 
 establishments, danger of spreading diseases by means of soiled clothes from 
 such houses has been greatly reduced. 
 
 From the foregoing facts it is evident that except for small-pox and typhus 
 fever, so far as the use of methods under consideration are concerned, the Balti¬ 
 more health department until 1898 or thereabout pursued a “ hands off 99 atti¬ 
 tude in regard to the diseases commonly regarded as spread by immediate and 
 mediate contact. It is equally clear that hospitalization of the sick and their 
 contacts, on account of the hopeless deficiency of hospital accommodations and 
 the character of the hospitals used, can have exerted no material influence in 
 checking the spread of any of these diseases when in epidemic form, with the 
 possible exception of small-pox. It must be quite patent, not only to those 
 experienced in public-health administration and to physicians, but to those of 
 the general public who have had experience with the course of anyone of this 
 whole class of diseases under the conditions above described, that the spread 
 of small-pox, typhus fever, diphtheria, scarlatina, measles, whooping-cough, 
 mumps, chicken-pox, and the like from one individual to another is rarely 
 influenced by such isolation of the sick and their contacts in typical homes and 
 institutions. Even in the rare instances in which the diagnosis of the first case 
 is made before all the susceptibles have been exposed, complete separation of the 
 inmates is impossible on physical and personal grounds. Therefore it would 
 appear that, under these conditions, even during the few years since about 1910, 
 that a sustained effort has been made by the health department to enforce isola¬ 
 tion of this type, in but a very small proportion of instances under the most 
 favorable conditions can this procedure have restricted the number of cases 
 among susceptibles in the populations exposed in the homes and institutions 
 under consideration. For the same reasons, even early hospitalization of the 
 11 
 
156 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 first cases can not be expected materially to cut down the number of primary 
 exposures in these groups; in the nature of the case, it can only, so far as these 
 persons are concerned, lessen the risk run of repeated or constant exposure. 
 That the cutting off of communication of the infected in dwellings by quaran¬ 
 tine procedures is an effective measure and capable, when complete, of pre¬ 
 venting the spread of the causes of the diseases under consideration to the 
 general community must be acknowledged upon a priori and experimental 
 grounds. There can be little doubt but that in the case of epidemics of small¬ 
 pox and typhus fever when dwellings harboring cases of these diseases were ade¬ 
 quately watched by reliable guards so that ingress and egress were certainly 
 prevented, this method has been effective. But experience has shown that with¬ 
 out trustworthy guards, except among the most intelligent and conscientious 
 portion of the population, on the whole in the minority, complete isolation of 
 the sick and their contacts from the general public is not obtained. It is well 
 known in the health department that certain elements, by no means small in 
 numbers, in the population consistently evade, or attempt to evade, regulations 
 in this regard. However this may be, with the exception of small-pox and typhus 
 fever, this restrictive measure was not seriously attempted in Baltimore for any 
 disease before 1898, when it was first applied to diphtheria, scarlatina, and 
 chicken-pox, to be followed in later years for whooping-cough, measles, mumps, 
 meningitis, and poliomyelitis. It can not be said that it was generally done for 
 all of these diseases before 1916, or that it was ever perfectly enforced for every 
 reported case of any one of them. 
 
 In regard to the value of disinfection by fire, heat, and chemicals, it may be 
 said that whatever virtue may reside in these procedures as commonly practiced 
 has been rewarded to Baltimore, for small-pox and typhus fever from early 
 days, for diphtheria, scarlatina, measles, and whooping-cough since about 1900, 
 and for pulmonary tuberculosis since 1905. That formaldehyde disinfection of 
 quarters occupied by the tuberculous, as practiced, could have had any notable 
 influence upon checking the spread of the cause of this disease is beyond the 
 bounds of reason. Only in the last few years has the health department advised 
 disinfection of the discharges of typhoid-fever patients, and it has never had 
 the forces to see that this advice has been consistently followed. 
 
 The effect of vaccine inoculation upon the course of small-pox, of typhoid 
 inoculation upon typhoid fever, of anti-rabies inoculation upon hydrophobia, 
 and of diphtheria antitoxin upon diphtheria will be considered in detail in the 
 separate discussion of these diseases. Suffice it to say here that before 1890 
 vaccination against small-pox was never pushed to the point of affording real 
 protection to the population, that anti-typhoid inoculation has been very little 
 practiced, and that there is evidence that the use of diphtheria antitoxin has 
 materially lessened the fatalities from that disease. 
 
 The measures inaugurated about 1912 and brought to a stage of precision 
 by 1916 to prevent the spread of certain diseases from households harboring 
 them by removal, until disinfected, of milk bottles and the like must have served 
 a useful purpose, particularly in regard to diphtheria, scarlatina, and typhoid 
 fever; but even here the protection has not been and probably can never be 
 perfect, for the method can not be put into operation until the cases are 
 reported, and before this is done some days (or even weeks in the case of typhoid 
 fever) have elapsed between the development of the disease and the application 
 of the restrictive measures. 
 
Chapter VII. —Administrative Officers and Sub¬ 
 divisions of the Health Department. 
 
 Commissioners of health; Vaccine physicians or health wardens; Divi¬ 
 sion of statistics; Plumbing division; Laboratories; Inspection of school 
 children; Nursing bureau; Bureau of communicable diseases; Bureau 
 of infant welfare; Miscellaneous services. (Tables 7-8.) 
 
 THE COMMISSIONERS OF HEALTH. 
 
 The early commissioners of health were laymen, and their main duties were 
 to try to keep the city clean and to enforce the nuisance ordinances. Theirs was 
 to act and not to think, and from such records as remain it would seem that 
 they strove earnestly and honestly to perform their tasks. On medical questions, 
 particularly in regard to the management of epidemics, they were advised 
 until 1821 by the health officer of the port, and from this date until 1839 by 
 the consulting physician. 
 
 Dr. Thomas E. Bond, consulting physician from 1821 to 1829, was a man 
 of eminence in his profession, and his annual reports reflected the current 
 thought of his time. He established public vaccination. 
 
 Dr. Horatio G. Jameson, 1830 to 1835, a student and thinker, and one of the 
 most accomplished physicians and surgeons of his day, was probably the ablest 
 man ever at the head of the department of health of Baltimore. He urged com¬ 
 pulsory general vaccination, to be routinely applied in infancy and repeated at 
 puberty. In 1832 he decided that cholera is not contagious in the usually 
 accepted sense and urged that it be fought by a general cleaning up of nuisances 
 and the establishment of a number of free dispensaries where the poor could 
 conveniently obtain prompt treatment while the disease was in the early stages. 
 He bitterly opposed a rigid system of quarantine as unnecessary and hurtful 
 to trade. Yellow fever had ceased to be a menace, diphtheria and scarlet fever 
 had not yet assumed epidemic prevalence in virulent form, typhus fever w r as 
 comparatively quiescent, and small-pox and malarial fever were regarded as 
 the chief problems. The former was to be controlled by vaccination and the 
 latter by draining and filling low places. Under his direction, and with Dr. 
 Samuel B. Martin as health officer of the port, the Baltimore health department 
 was, relatively speaking, at its zenith. 
 
 Dr. John Hanson Briscoe and Dr. Robert A. Durkee, consulting physicians, 
 1836 to 1838 and 1842 to 1844, respectively, left no evidences of particular 
 talent or activity. 
 
 With the revival of the board of health with medical representatives in 1839, 
 Dr. Thomas E. Bond became the first president and executive officer. He w r as 
 succeeded by Dr. Charles E. Davis in 1840 and 1841. With its reestablishment 
 in 1845, the presidency of the board was held for six years by Dr. William T. 
 Leonard, who was succeeded by Dr. S. R. Clark, 1851 to 1852. Dr. Leonard 
 was a man of some ability and was particularly active in pushing vaccination. 
 
 157 
 
158 
 
 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 Dr. William H. Kemp, as commissioner of health and city physician, was 
 the head of the department from 1853 to 1860. During the yellow-fever epi¬ 
 demic in the cities at the mouth of the Chesapeake, he kept up open communi¬ 
 cation and received refugees. He played an important role in the National 
 Congress on Quarantine held in 1856. 
 
 Of the next three commissioners at the head of the department, Dr. Charles 
 H. Bradford, 1861, Dr. S. T. Knight, 1862 to 1864, and Dr. G. E. Morgan, 
 1865 to 1870, Knight was the only one of more than ordinary ability, and no 
 one of them made any signal improvement in methods or measures. 
 
 Dr. Milton N. Taylor, 1870 to 1871, a respectable and amiable practitioner, 
 showed no powers as an administrator; but his reports give evidence of a 
 broader outlook upon matters relating to environmental conditions, for he advo¬ 
 cated the establishment of numerous small parks in congested districts as 
 breathing-spaces for the poor and the planting of trees throughout the city to 
 afford shade in the hot weather and as a means of reducing surface and ground 
 water. 
 
 Dr. George W. Benson was commissioner of health in 1872 and 1873 and in 
 1882 and 1883, when it fell to his lot to fight two of the most severe epidemics 
 of small-pox in the history of the city. He was a vigorous and determined 
 administrator and left the most complete and accurate records of vaccinations 
 and of reported cases to be found in the reports. 
 
 Dr. James A. Steuart, who was in charge of the department as commissioner 
 of health from 1873 to 1889, with the exception of the two years 1882 and 1883, 
 devoted most of his time and energies to the work. With an attractive person¬ 
 ality, a high standing in the medical profession and in the community, and a 
 decided taste for the work, and being well read in the literature of hygiene 
 of his day, he possessed many of the qualifications for leadership in public- 
 health administration. However, his deficiency in the requisite knowledge of 
 the natural sciences and of pathological anatomy and his inability to compre¬ 
 hend the rapidly growing literature of micro-parasitology were handicaps that 
 prevented his rising to the full height of his opportunities. Thoroughly con¬ 
 vinced that most of the communicable diseases are due to gaseous emanations 
 from putrefactive processes, early in his adminstration he fell a complete 
 convert to the sewer-gas theory of disease causation, and he busied himself 
 chiefly with increasing the machinery of the department to deal with common 
 nuisances, which were multiplying in geometric ratio to the growth of the pop¬ 
 ulation. In this field, his greatest contribution was the establishment of plumb¬ 
 ing inspection and the employment of chemists to examine market milk and 
 well and spring waters. He had a decided interest in vital statistics, secured an 
 ordinance requiring the certification of deaths and of births, and was very suc¬ 
 cessful in having the latter recorded. It was during his administration that 
 there was begun the compilation and publication in the annual reports of elab¬ 
 orate statistical tables of deaths expressed in absolute figures. Dr. Steuart laid 
 considerable stress upon the use of statistics in administration. Curiously 
 enough, he made no consistent effort to secure the reporting of cases of com¬ 
 municable diseases. 
 
 Dr. Steuart was succeeded by Dr. George F. Kohe, 1890 to 1892, a man of 
 considerable talent, force, and executive ability, combined with a good training 
 
PUBLIC HEALTH ADMINISTRATION OF BALTIMORE 
 
 159 
 
 in medicine and a taste for hygiene, on which he wrote a small text-book. Rohe’s 
 reports showed a decided grasp of public-health problems, and that he did not 
 retain office was a distinct misfortune to the city and to the cause of public 
 health in general. Had he continued in office a few more years the city would 
 have gained at least 10 years in progress. 
 
 Rohe was succeeded by Dr. James F. McShane, a man of more than average 
 native ability, but of defective training in the natural sciences and in medicine, 
 and but little acquainted with the literature of his subject. He had had the 
 advantage, however, of some years’ experience as assistant commissioner under 
 Steuart and Rohe, from whom he evidently absorbed some ideas. McShane was 
 open to suggestions from the leaders in the medical profession, and his admin¬ 
 istration, 1892 to 1897, was marked by the establishment of the laboratories of 
 chemistry and bacteriology in the department and by the recognition of the 
 importance of reporting communicable diseases. He appreciated the necessity 
 of changing the traditional methods of the department. He made some investi¬ 
 gations into the epidemiology of typhoid fever and recognized that it may be 
 spread in a variety of ways. He early recognized the value of diphtheria anti¬ 
 toxin and secured its use free of charge to those unable to pay for it. He had 
 no ideas of his own, did not inspire confidence, and completely failed to attain 
 a position of leadership at a time when the leadership of a commissioner of 
 force, talent, and broad knowledge would have been of the highest value to 
 the city. 
 
 Dr. C. Hampson Jones succeeded to the commissionership in 1898 and 
 brought to the office native talent and a real interest in public-health adminis¬ 
 tration, but unfortunately, like Rohe, he held the office for two years only, a 
 time too short to reorganize the methods and to change the attitude of the 
 department very materially. Fortunately for the department, he was retained 
 as assistant commissioner from 1900 to 1915 and was reappointed commissioner 
 in the fall of 1919. 
 
 Dr. James Bosley w r as commissioner of health from 1900 until his death in 
 1913. A man of considerable personal charm and a physician of good repute 
 with a large general practice, but untrained in pathology and in micro- 
 parasitology at a time when these branches dominated the whole field of hygiene, 
 and unacquainted with the literature of hygiene, he was almost entirely lacking 
 in the qualifications necessary for the proper filling of his office. He was gen¬ 
 erally beloved in the department, in which in a short time he became little more 
 than a figurehead. His unexpired term, from January 1913 to October 1915 
 was filled by Dr. Nathan N. Gorter, a surgeon of good social and professional 
 standing, who was a conscientious official with high aspirations and ever anxious 
 to improve the scope and efficiency of the health department. Without distinct 
 ability as an administrator or any special knowledge of hygiene and the prob¬ 
 lems pressing for solution, he exercised no influence of lasting importance in 
 the department. 
 
 For the 18 years 1897 to 1915, as commissioner and assistant commissioner, 
 Dr. Jones was the real force in the department, and the changes in the attitude 
 and the innovations in measures that marked this critical period were very clear¬ 
 ly his contributions. In many matters he derived help from the expert knowl¬ 
 edge of his colleague, Dr. Stokes. Dr. Jones was handicapped by lack of direct 
 
160 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 authority in the department and had to address the city authorities through 
 the medium of the commissioner. He had to do the work of incompetent com¬ 
 missioners as well as his own, much of the time without adequate and trained 
 assistance. In consequence, organization of the department was incomplete, 
 and measures and methods formulated constantly fell short of his plans. Given 
 a free hand, with his intimate knowledge gained by long experience and hard 
 study of the needs of the department, Dr. Jones might have accomplished much 
 more than the very considerable reformations he instituted. 
 
 The last commissioner of health serving during the period under review was 
 Dr. John D. Blake, whose term of office covered the four-year period ending in 
 October 1919. Dr. Blake, who was a physician and surgeon of wide experience, 
 accepted office at a relatively advanced age. Of a genial nature, and with a 
 strict sense of justice and probity, Dr. Blake evinced a sincere desire to devote 
 himself to the public service. Like so many of his predecessors, however, he 
 was untrained in public-health administration, lacking in first-hand knowledge 
 of micro-parasitology, and not well versed in the literature and methods of 
 modern hygiene. Though considerable advances in the methods and scope of 
 the work of the department were made during his administration and he was 
 ever ready to consider suggestions, these handicaps seriously impeded the 
 reorganizations and readjustments indicated by present-day knowledge. 
 
 The main object of this review will be missed if it has not been made apparent 
 that the chief factor determining the activities and accomplishments of the 
 health department, or, in other words, its actual value to the city, has been the 
 fitness of the chief medical officers. A man of high talent, sound judgment, and 
 accurate and comprehensive knowledge to formulate appropriate policies, and 
 force of character to impress them on the authorities, the profession, and the 
 general public and gain the power to carry them out, is a tower of strength as 
 the head of a health department. Such a one has been rare. Jameson was the 
 only man long at the head of the Baltimore health department who met these 
 qualifications in any high degree. Rohe might have reached them in con¬ 
 siderable degree had he remained longer in office. The most amiable and earnest 
 commissioner, lacking in knowledge and in capacity and desire to learn, may, 
 with the best intentions, set back the clock for years. On the other hand, most 
 of the men at the head of the health department were, on the whole, about as 
 useful and capable as any who could have been got to serve under the conditions 
 obtaining. 
 
 A great drag on the logical development of an intelligent and adequate 
 public-health administration in Baltimore has been the indifference, except in 
 times of great epidemics, of the public and of the administrative and legislative 
 authorities at certain periods of the city’s history, and this has been influenced 
 to a certain degree by the periods of excessive immigration. The dilution 
 of civic solidarity by the influx of people of lower standards of intelligence, 
 education, and living conditions must always not only increase the problems 
 but decrease the effectiveness of administration. The continuity of plans and of 
 their development is broken by the necessity of meeting new and sudden 
 demands, and the influence of the more progressive and intelligent leaders 
 among the older citizenship is diffused over a larger and less ductile mass and 
 consequently lessened. The disgraceful years of rioting, interference with 
 
PUBLIC HEALTH ADMINISTRATION OF BALTIMORE 
 
 161 
 
 voting by bands of “ plug-uglies,” and the weak and corrupt civic administra¬ 
 tion of the fifth and sixth decades of the last century were intimately associated 
 with such a period of massive immigration. The military government during 
 the Civil War, the great losses to business and commerce associated with that 
 war and its consequences, and the long period of political corruption and of 
 administrative inefficiency that followed, reacted on public-health administra¬ 
 tion. The general apathy of the public to sanitary improvements is well illus¬ 
 trated by the attitude toward establishing a system of sanitary sewers, repeat¬ 
 edly proposed, and toward the water-supply. During these periods only men of 
 extraordinary power could have exerted a decided influence in the health office. 
 Another great setback in one sense, but of some general sanitary gain in another, 
 was the great fire of 1904. The energies of mayors of a type decidedly above 
 their immediate predecessors, which might have been devoted to sanitary 
 reforms and the placing of stronger men in the health department, were thus 
 diverted to other directions. 
 
 While many of the mayors of Baltimore were men of distinct ability and none 
 of them were lacking in concern for the general welfare, it is a fact of impor¬ 
 tance that comparatively few of them evinced a continuing interest in and a 
 critical insight into the problems of public-health administration. Of those 
 who exhibited these qualities, Dr. Edward Johnson, 1818 to 1822, and Mr. 
 James H. Preston, 1911 to 1919, stand out conspicuously. The former was 
 deeply concerned in the measures for the restriction of yellow fever and malaria. 
 
 Another serious drag on development of ideas and improvement in measures 
 and methods in the health department was the distinct lowering of the standard 
 of the medical profession of the city after 1870, traceable to the growth and 
 influence of the proprietary medical schools that flourished between 1872 and 
 1910. Many of the medical graduates turned out were for their times relatively 
 much inferior in intellect, general and professional education, and standards 
 than the men whom they replaced. 
 
 SUBORDINATES IN THE HEALTH DEPARTMENT. 
 
 While in the early years subordinates in the health department may have 
 been carefully selected for personal fitness for their work, there is nothing in 
 the records to show that this was generally true. So far as tradition goes, with 
 a few exceptions, appointments to all offices from commissioner down have 
 been governed by partisan politics. Of late years reformers and aspirants for 
 political advancement have dwelt upon this point, and it has been freely 
 acknowledged by the professional politicians. The professional politicians, in 
 a sense, act as employment agencies; but, unlike the usual agencies for this 
 purpose, they assume a double responsibility, for they must to a considerable 
 degree look out for the interests of both employer and employee. The usual 
 business agency is interested primarily in getting a job for the employee, but 
 the politicians have a direct interest in seeing that, to some degree at least, the 
 employer is not illy served. The history of the health department shows that a 
 large number of employees, appointed primarily on political grounds, have 
 been faithful, conscientious, hard-working, and intelligent servants of the 
 public for years, with a commendable pride in their work, at which, in times 
 of stress, they have slaved for long hours overtime without a murmur, without 
 
162 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 any chance of extra pay, and without public recognition. For many years, for 
 positions requiring technical skill and training, as the heads of the laboratories 
 of chemistry and bacteriology, for instance, the incumbents have been chosen 
 primarily for these qualities. Many valuable assistants have been trained in 
 these laboratories from promising material and given the chance of advance¬ 
 ment to higher posts on pure merit. Some of them have been called away to 
 more remunerative positions in industries and made way for others to rise in 
 their places. The heads of the division of plumbing have always been master 
 plumbers of honesty and capacity and have so conducted the work that dis¬ 
 honesty soon becomes glaring and meets its just reward and shirkers are 
 crowded out. 
 
 That there were many incompetents and a considerable number of misfits 
 there is no question, but actual practical work in the department was the only 
 school available to subordinate employees, and only the few can grasp the 
 details of new labors without careful oversight and instruction, and under no 
 system of appointment will the lazy exert themselves without prodding. Where 
 subordinates have this treatment from an immediate superior, backed by the 
 commissioner, good service to the city has commonly resulted. 
 
 The defects in the administration of the health department are not explained 
 satisfactorily on the common assumption that they were due in the main to the 
 inefficiency of subordinates steeped in partisan politics and forced on an un¬ 
 willing commissioner by political bosses. To a degree not generally recognized, 
 the commissioners have been responsible for these short comings. It is the 
 duty of a commissioner of health to set policies and standards, to train his 
 personnel, and to see that the work is done promptly and affectively, that misfits 
 —unavoidable under any system of appointment—are properly placed, and that 
 the incompetent and the shirker are weeded out. Too often has a commissioner 
 failed in one or more of these respects and it has fallen to the lot of the assis¬ 
 tant commissioner, without power to inaugurate or to change policies and to 
 promote or demote subordinates, to attempt to discharge the duties of two men. 
 
 THE VACCINE PHYSICIAN AND THE 
 HEALTH-WARDEN SYSTEM. 
 
 In 1821, in order “ to extend the benefits of vaccination ” to the poor and 
 probably with the design of relieving the members of the Medical and Chirurgi- 
 cal Faculty of a burden which they had voluntarily assumed, an appropriation 
 of $400 was made by the city for the appointment in the health department of 
 four public vaccinators to be called vaccine physicians. The system was organ¬ 
 ized and the physicians were chosen by a committee of the faculty. As at first 
 intended and practiced, there was no compulsion exercised on the public to 
 submit to vaccination by these four physicians; their services were freely 
 extended to those who desired them but who could not afford to pay the charges 
 of private practitioners. The vaccinators made monthly reports to the health 
 department of the number of vaccinations made and of their success or failure. 
 It was not until the small-pox epidemic of 1831 that, in addition to their origi¬ 
 nal duties and as part of the administrative program of the department against 
 this disease, they were ordered to vaccinate, nolens volens , the contacts of cases 
 
PUBLIC HEALTH ADMINISTRATION OF BALTIMORE 
 
 163 
 
 of 6mall-pox and were detailed to make a house-to-house canvas for hidden cases. 
 In 1827, the number of vaccinators was raised to six and in 1831 it was 
 doubled, one for each city ward. 
 
 By ordinance of 1853, it was made the additional duty of the vaccine physi¬ 
 cians to be on the outlook for cases of any “ pestilential ” disease and for 
 nuisances dangerous to health in their wards, which they were to report to the 
 health office. By the charter of 1900, a vaccine physician for each ward was 
 prescribed, who, in addition to his other duties, was to act as health warden, 
 and thus the vaccine physicians were raised officially to the status of wardens 
 of health. Their duties were very much expanded in the eighth decade of the 
 last century, when vaccination was made compulsory and an ever-increasing 
 proportion of the people availed themselves of the privilege, now extended to 
 every one, of free vaccination. When the street-cleaning and garbage and ash 
 removal were taken out of the health department and its nuisance force was 
 thereby cut down to a minimum, the health warden gradually evolved from a 
 reporter to an abater of nuisances of various sorts. The health wardens were 
 relieved of some of the latter duties by the inspectors of nuisances until 1895, 
 but from this date until 1916 the chief function of the health warden was the 
 control of ordinary nuisances, and, in many wards, the inspection of cellars, 
 yards, toilets, privies, leaking pipes and rain gutters, and dirty and ill-paved 
 yards, alleys, and streets obscured their medical activities. The latter were 
 much expanded during and after the commissionership of Dr. C. Hampson 
 Jones in 1898, when concerted efforts, very largely carried out by the health 
 wardens, were instituted against various communicable diseases. 
 
 Since 1916, the nuisance work of the health warden has been considerably 
 abridged, partly because of the improved grading and paving of streets and 
 alleys and the completion of the dual sewage system, and partly because of the 
 shifting of most of it to the division of plumbing. He has in consequence been 
 restored to his original status of medical officer of health in his ward, in charge, 
 under the direction of an assistant commissioner of health, of public vaccination 
 and of other activities directed to the control of diseases transmissible by per¬ 
 sonal contact. To this end he must visit each reported case, give instructions, 
 establish isolation in homes and institutions, take cultures, make diagnoses, 
 issue discharge certificates, and obtain and file a history of each case. 
 
 The vaccine physicians and health wardens always have been physicians in 
 active practice, giving so much of their time to the work of the department as 
 was demanded. Their salary has always been incommensurate to the time 
 devoted and the character of the services rendered, and, owing to lack of proper 
 organization of the work of the department, much of their time has been wasted 
 unnecessarily. 
 
 The health wardens and the system have been much criticized and maligned, 
 particularly by the unthinking and the uninformed of a class that, recognizing 
 that something was radically wrong with the department and believing that all 
 the evils affecting mankind center in the nuisances the health wardens were sup¬ 
 posed to abate (an impossible task under the physical conditions obtaining), 
 laid the defects at their door. As a matter of fact, the typical vaccine physician 
 or health warden has always been a physician of more than the average intel¬ 
 ligence, training, diagnostic ability, and knowledge of the natural history of 
 
164 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 disease, and certainly, in knowledge and experience in Ills work, the superior 
 of any commissioner of health between 1900 and 1919. Many able physicians, 
 such as G. W. Miltenberger, Frank Donaldson, Charles Frick, William F. Lock- 
 wood, N. G. B. Iglehard, for instance, who afterwards reached distinction, did 
 not scorn the office in their earlier years. 
 
 DIVISION OF STATISTICS. 
 
 Since the establishment of the health department the records of deaths, since 
 1875 the records of births, and since 1882 the records of reported cases, have 
 been kept by clerks under the supervision of the chief medical officer. For many 
 years the records of births, and deaths, and cases have been kept and tabulated 
 in separate divisions. In both form and content the general and special tabula¬ 
 tions published in the annual reports have been directed and supervised by the 
 commissioners or by the assistant commissioners of health. Neither the statis¬ 
 tical clerks nor their supervisors have had formal training in statistical methods 
 and their competence has not extended beyond the capacity to follow with con¬ 
 scientious fidelity the customs and rules of classification of deaths, births, and 
 reported cases, to perform addition correctly, to set up simple tables, and to 
 calculate crude rates. 
 
 DIVISION OF PLUMBING. 
 
 When supervision of plumbing was first provided for in 1883, with provision 
 for an inspector with power to frame proper rules therefor, subject to the 
 approval of the Board of Health, the evident intent of the law was to limit 
 operations to new installations. But the inspector soon found many nuisances 
 in connection with old installations, which were reached under the general 
 powers of the board. These nuisances were associated chiefly with poor design 
 and materials and lack of repair, giving rise to odors, leaks, and overflows, 
 both within and without dwellings. These conditions and their causes and 
 proper remedies were ably treated and illustrated with drawings by the inspector 
 of plumbing, John W. Lee, in his report for 1886. Among other things he found 
 to condemn were lack of vents for privy-wells, the filthy condition of water- 
 closets and bath-tubs, often inclosed with foul-smelling and rotten woodwork, 
 and the use of the old pan type of water-closet. Strongly convinced of the 
 potency of sewer-gas as the prime cause of acute diseases, and backed by a 
 commissioner wedded to this theory, he set to work to rectify these conditions. 
 From the beginning, therefore, the activities of the plumbing division have been 
 to regulate and correct existing nuisances by ordering, where deemed necessary, 
 repairs or renewals amounting to new installations, to see to it that all new 
 installations were in design, material, and workmanship proper for their 
 purpose. These factors, of course, led to the establishment of standards on which 
 permits for work were based, and of a system of inspection of work in progress 
 to see that these standards were met. 
 
 It is a matter of interest that the plumbing department has sought to protect 
 the property-holder by insisting that plumbing work shall be done in a “ work¬ 
 man-like ” manner, that is, according to the standards of ethics and practice 
 recognized as proper in the trade. A second activity of importance was the 
 
PUBLIC HEALTH ADMINISTRATION OF BALTIMORE 
 
 1G5 
 
 system of inspection of complaints, involving advice and requirements for 
 the abatement of nuisances connected with plumbing, and covering a great 
 variety of conditions. A third duty was the clearing of stoppages of public and 
 private sewers, and to a certain degree the oversight of cesspools. By 1898 the 
 duties and standards of the plumbing department had reached a point where 
 the commissioner of health felt warranted in issuing a set of rules and regula¬ 
 tions, which had the effect of a code of plumbing. The section on plumbing 
 of the building code of 1908 represents an expansion of these regulations. 
 
 With the partial completion of the new sewage system in 1911, the work of 
 the division of plumbing was enormously increased, and the personnel was corre¬ 
 spondingly expanded, to force and to oversee connections. The sewer laterals 
 were extended to the building-line of each property, and all connections thereto 
 were made under the supervision of the division of plumbing. This work, 
 which required an immense amount of detailed planning and supervision and 
 considerable executive ability, was pushed when the sewers were ready for con¬ 
 nections and was successfully completed for the sewered districts in 1918. 
 
 The annual reports and observation of their work and methods show that 
 the successive chief inspectors of plumbing have been faithful public servants, 
 men of integrity, judgment, and courage, who have well filled positions of 
 responsibility. 
 
 LABORATORIES. 
 
 The establishment of the laboratories of chemistry and of bacteriology in 
 the health department dates from 1896. Though started under different 
 conditions and maintained always as separate departments, their work, while 
 remaining separate and distinct in certain fields of activity, soon became closely 
 interwoven. 
 
 CHEMICAL LABORATORY. 
 
 The laboratory of chemistry evolved by slow stages, under the needs of the 
 commissioners of health for expert advice and assistance in attempts to improve 
 and control the milk and water supplies. This began with the employment of 
 Professor William P. Tonry, of the Maryland Institute, by Commissioner 
 Steuart, to examine samples of milk in 1873 and of well and spring waters in 
 1876 and 1885. As a result of these examinations, Commissioner Steuart 
 started a campaign against city wells in 1876. In 1892, Commissioner McShane 
 employed another chemist, Professor P. D. Wilson, to conduct examinations 
 of the waters of streams tributary to the Lake Roland water-supply. 
 
 Though Professor Tonry’s valuable reports on the milk supply in 1873 
 showed that much of the milk was deficient in butter fats, watered, and filled 
 with impurities, no steps were taken by the city government to furnish the 
 commissioner of health with means and personnel to enforce the weak ordinance 
 of 1855 and the similar ordinance of 1879, forbidding the mixing of water and 
 any drug with milk offered for sale. 
 
 Dr. Tonry was appointed chemist to the health department in 1894, under 
 the provisions of the food ordinance of that year. He used his private laboratory 
 until 1896, when provision for a small chemical laboratory in the health depart¬ 
 ment was made. Dr. Tonry made a comprehensive study of the sources of the 
 Baltimore milk-supply, the conditions under which it was produced, handled, 
 
166 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 and sold, and started a system of inspection to prevent adulteration by addition 
 of water, adulterants, and preservatives. An important part of his work was 
 the organization of inspection and improvement of cow stables, and the feeding 
 of milch cattle, which finally, by making it unprofitable, served to force most of 
 these places to discontinue operations. Examination of well and spring waters 
 was inaugurated, and of preserved foods, to which suspicion was directed. 
 
 In 1895, the cause of the sudden illness of 17 people was proven to be due 
 to arsenic present in a barrel of pickles sold at a grocery. 
 
 The reports of Dr. George W. Lehmann, who succeeded Professor Tonry in 
 1896, show that creditable work was done in inspection and analysis of the 
 milk and water supplies. In 1896, the work of food inspection was expanded 
 by adding inspection of bakeries and confectioneries, and in 1900 this inspection 
 was extended to markets and slaughter-houses, resulting in the condemnation 
 of large quantities of meats and vegetables as unfit for food. 
 
 By the gradual addition of inspectors and the reference to them by the com¬ 
 missioner of health, usually on complaint of citizens, of different types of food 
 for examination, the chemist became the head of an administrative department, 
 guarding the purity of the food-supply. Where legal standards established by 
 ordinance or by state legislature were lacking, they were supplied by ukase of 
 the commissioners of health. The reports of chemical determinations and of 
 inspections and condemnations made are full and, for the purposes of sanitary 
 administration, very informing. In 1903, an extensive inquiry was made into 
 the adulteration of milk sold in small stores, particularly for the use of the 
 babies of the poor, and into the quality and composition of condensed milk used 
 for this purpose. It was calculated, from the number of cans of the latter sold, 
 that at least 960,000 gallons of this material in the dilutions recommended by 
 the manufacturer were used each year in the city. Pus organisms and other 
 bacteria being present in numbers in samples from original packages, and the 
 chemical analysis showing evidences of adulteration, standards of purity for 
 condensed milk were set and enforced. 
 
 The activities of the department had been expended by 1910 to include 
 inspection of dairy farms supplying milk to the city and supervision of the 
 pasteurization of milk and cream (a considerable number of dealers having 
 voluntarily adopted pasteurization), better control of the physical conditions 
 under which milk was handled and sold (especially the general sanitation of 
 small milk shops), and the inspection of meats and meat products at slaughter¬ 
 houses. At the same time, the chemical analysis of foods and drugs for adultera¬ 
 tion had expanded. 
 
 By 1915 the chemist presided over a bureau of chemistry and food inspection, 
 with several assistants and a large force of inspectors. There were analyzed 
 regularly the city water, the milk, cream, ice-cream, condensed milk, canned 
 and prepared foods, and the like. Dairy farms, dairies, milk-wagons, slaughter¬ 
 houses, wholesale and retail markets, stores, bakeries, and confectioneries were 
 inspected and pasteurization of milk was supervised. The scope of the meat 
 and dairy and milk inspection and of the water control are considered in other 
 chapters. 
 
 The most useful work of this division of the health department has undoubt¬ 
 edly been in connection with water and milk, and of all the activities in this 
 
PUBLIC HEALTH ADMINISTRATION OF BALTIMORE 
 
 167 
 
 relation, the enforcement of the milk ordinance of 191? was perhaps its most 
 significant accomplishment of value. Viewing this work from the standpoints 
 of its possible, probable, and known benefit to the public health, it does not 
 appear that much has been accomplished through the system of dairy-farm 
 inspection. In adopting it and in relying too heavily upon it, the department 
 followed the fashion of the time. Much more would have been accomplished 
 with the same force in guarding the milk-supply after its receipt within 
 the city. 
 
 The progress of correcting the evils connected with the milk-supply, while 
 slow, was in the end effective, and each advancing step accomplished something 
 of value in the direction of safeguarding the public health. To those unfamiliar 
 with the complex forces, both static and dynamic, within and without the city, 
 to be overcome at each step, appreciation of the full value of these services is 
 impossible. 
 
 In its work, the division or bureau of chemistry has worked in active coopera¬ 
 tion with the bacteriological laboratory. 
 
 BACTERIOLOGICAL LABORATORY. 
 
 This laboratory was established in 1896, on the recommendation of Com¬ 
 missioner McShane, supported by a committee of the 'Medical and Chirurgical 
 Faculty. The immediate stimulus was the recent discovery of the diphtheria 
 antitoxin and of the culture method for the certain and rapid diagnosis of 
 diphtheria. Dr. William Royal Stokes has served continuously as bacteriologist. 
 This laboratory from the first offered physicians the services of bacteriological 
 methods for the rapid diagnosis of diphtheria, pulmonary and other forms of 
 tuberculosis, malaria, gonorrhoea, and certain other affections, and later, as 
 methods were introduced, of typhoid fever, rabies, meningitis, poliomyelitis, 
 pneumonia, and syphilis. This laboratory has never produced diphtheria and 
 tetanus antitoxin and other antisera, nor vaccine virus, but has prepared anti¬ 
 typhoid vaccine in large quantities. Dr. Stokes early turned his attention to 
 bacteriological analyses of the water-supply and of the milk of Baltimore, and 
 independently and in collaboration with the chemist, he has made extensive 
 and valuable studies of these. The annual reports from this laboratory contain 
 accounts of creditable studies and interpretations of their relation to public 
 health in Baltimore. Among the studies of greatest value are those relating 
 to the water-supply, particularly the introduction and control of chlorinization 
 in 1911, and the investigations of the presence of pus and of pathogenic organ¬ 
 isms in milk, especially in relation to inflammatory mastitis and tuberculosis 
 of milch cattle. The large scale on which diphtheria-culture tests are used in 
 the bureau of communicable diseases for release and detection of possible 
 carriers in institutions, schools, and homes, was made possible through 
 Dr. Stokes’s cooperation and largely on his suggestions. 
 
 Throughout its history the bacteriological laboratory has offered diagnostic 
 and other services far in advance of their utilization by the medical profession 
 and the public, and judged by the character of its accomplishment, within the 
 limitations in means and personnel allowed it by the city government, it com¬ 
 pares favorably with that of any other city. 
 
168 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 SCHOOL INSPECTION. 
 
 School inspection started in 1905 with 2 physicians and 1 trained nurse. 
 Beginning in 1906 with 5 physicians and 5 nurses, medical inspection of school 
 children, at first confined to the public schools, was soon extended to the 
 parochial and to some of the private schools, and as a routine matter it has 
 been limited to children of kindergarten age and of the first four grades of 
 grammar schools. The routine inspections have always been restricted to physi¬ 
 cal defects, cleanliness, and evidences of successful vaccination. The city is 
 divided into five districts, embracing approximately the same number and 
 type of schools and pupils, and a physician and nurse are assigned permanently 
 to a particular district. The physicians are allowed considerable latitude as to 
 methods, but they use the same record forms. The usual procedure, starting in 
 the fall, is for the nurse to go through the lower grades to inspect first for 
 evidences of successful vaccination and for vermin. Her attention is called by 
 the teachers to those children who obviously are defective in seeing, hearing, 
 breathing, or who in any other way seem abnormal, and in addition the nurse 
 looks and inquires for children with chronic coughs, anemia, and the like. All 
 children lacking evidences of vaccination, or who have or are suspected of 
 having defects, are brought before the school physician at his morning visit, 
 which lasts from one to three or more hours each school day until all the exam¬ 
 inations are completed. 
 
 The examinations are confined practically to physical inspection—head, 
 eyes, ears, nose, throat, neck, and extremities. Only exceptionally do they go 
 further and embrace examination of the chest for diseases of the heart and 
 lungs. Where acute febrile disease is evident or suspected, the temperature 
 and the pulse-rate may be taken. No routine examination is made for the acute 
 diseases of childhood. No medical treatment is prescribed or given by the 
 physicians. Exclusion is ordered for lack of evidence of successful vaccination, 
 for vermin, impetigo, sore throat, and the usual contactive diseases of childhood 
 when discovered. Cards recording the cause for exclusion are sent to the 
 parents, and the health department is notified of cases falling under the list of 
 reportable diseases. In cases of defects or diseases of the eyes, ears, nose, tonsils, 
 and teeth, and of evident anemia or suspected tuberculosis, and the like, the 
 parents are advised to consult the family physician or an appropriate dispensary 
 service. In a large proportion of cases of the latter group, nothing is done 
 unless the children are followed up in their homes by the nurse, and the mother 
 is besought to seek medical advice. Children with defects of eyes, ears, nose, 
 throat, and teeth are often taken in parties by the nurse to the dispensaries for 
 examination and treatment. In many cases of children infested by vermin, 
 usually head and body lice and scabies, the nurse applies the appropriate reme¬ 
 dies in the home, often, of course, finding it necessary to treat the whole family. 
 In 1917 the number of school nurses was doubled. 
 
 The physicians have returned each year reports with lists of the numbers of 
 pupils examined and the number of defective and those instances in which 
 each of the more usual defects were found. These data are sometimes given 
 in some districts for each separate school. The percentage of defects found 
 vary widely in the various schools. Taking Dr. H. Warren Buckler’s report for 
 1908 as an example of 20 schools, the lowest and highest percentages of defec- 
 
PUBLIC HEALTH ADMINISTRATION OF BALTIMORE 
 
 169 
 
 tives were 22.9 and 49 respectively. Under the various headings, the highest 
 and lowest percentages were as shown in table 7. 
 
 To take another year as an example, tables are given in the report of 1911 
 
 Table 7. 
 
 Defects. 
 
 Highest 
 
 percentage. 
 
 Lowest 
 
 percentage. 
 
 Eye and ear. 
 
 12.3 
 
 3.0 
 
 Nose and throat. 
 
 24.7 
 
 7.0 
 
 Communicable parasitic diseases. 
 
 20.3 
 
 1.0 
 
 Filth . 
 
 8.1 
 
 0.0 
 
 Malnutrition . 
 
 9.0 
 
 0.0 
 
 Imperfect teeth . 
 
 36.9 
 
 6.5 
 
 Unvaccinated . 
 
 2.4 
 
 0.0 
 
 showing the total number of pupils examined in the public and parochial schools 
 and the number of instances in w 7 hich various “ defects ” were recorded. 
 
 Table 8. —Number and 'proportion of children with defects and diseases, compiled from 
 the Annual Report of the Health Department of Baltimore, 1911. 
 
 Affection. 
 
 • 
 
 White. 
 
 Percentage 
 
 affected. 
 
 Colored. 
 
 Percentage 
 
 affected. 
 
 Total. 
 
 Percentage 
 
 affected. 
 
 No. of pupils. 
 
 47,401 
 
 • • • • 
 
 5,318 
 
 • • • • 
 
 52,719 
 
 • • • • 
 
 Sick and disordered, all causes. 
 
 24,509 
 
 51.71 
 
 2,378 
 
 44.72 
 
 26,887 
 
 51.00 
 
 No. unvaccinated . 
 
 2,392 
 
 5.05 
 
 210 
 
 3.95 
 
 2,602 
 
 4.94 
 
 Pediculosis . 
 
 4,377 
 
 9.23 
 
 103 
 
 1.94 
 
 4,480 
 
 8.50 
 
 Adenoids . 
 
 3,435 
 
 7.25 
 
 319 
 
 6.00 
 
 3,754 
 
 7.12 
 
 Rhinitis . 
 
 980 
 
 2.07 
 
 128 
 
 2.41 
 
 1,108 
 
 2.10 
 
 Enlarged tonsils. 
 
 4,761 
 
 10.04 
 
 522 
 
 9.82 
 
 5,283 
 
 10.02 
 
 Eye strain . 
 
 1,752 
 
 3.70 
 
 210 
 
 3.95 
 
 1,962 
 
 3.72 
 
 Total eye defects. 
 
 3,045 
 
 6.42 
 
 347 
 
 6.53 
 
 3,392 
 
 6.43 
 
 Ear defects . 
 
 263 
 
 0.55 
 
 21 
 
 0.39 
 
 284 
 
 0.54 
 
 Teeth defects . 
 
 7,056 
 
 14.89 
 
 794 
 
 14.93 
 
 7,850 
 
 14.89 
 
 Adenitis (cervical lymph-glands enlarged) 
 
 797 
 
 1.68 
 
 103 
 
 1.94 
 
 900 
 
 1.71 
 
 Tuberculosis, various organs. 
 
 64 
 
 0.14 
 
 20 
 
 0.38 
 
 84 
 
 0.16 
 
 Mentally defective. 
 
 254 
 
 0.54 
 
 21 
 
 0.39 
 
 275 
 
 0.52 
 
 Debility . 
 
 617 
 
 1.30 
 
 49 
 
 0.92 
 
 666 
 
 1.26 
 
 Table 8 must be interpreted with care. It is evident that some pupils have 
 more than one “ defect.” The high proportion of cases of pediculosis, the 
 greater number of which occurring among whites, was due to the fact that in 
 some of the white schools many or most of the children were so affected, while 
 in most of the white schools none of the pupils were infested. The text of the 
 reports shows that only in certain schools were there instances of pediculosis, 
 and from these it was difficult to eradicate it, owing to the habits of the people. 
 Pediculosis among the whites, except for accidental infestion arising in school 
 
170 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 contact, was confined to certain races of more recent immigration. In a few 
 years, through the effective work of the school nurses, the schools were practi¬ 
 cally rid of this affection. For the other defects, these figures, except for the 
 category of mental deficiency, probably give an accurate picture of their dis¬ 
 tribution in the population under consideration. Some of the most common 
 defects noted occur together frequently, such as enlarged tonsils, adenoids, 
 rhinitis, and enlarged cervical lymph-glands. These perhaps might be grouped 
 together without serious error as affecting between 5 and 7 per cent of the whole 
 number of pupils. The most important categories are the large proportion of 
 cases of eye-strain and other abnormalities of the eyes (3.72 per cent and 6.43 
 per cent, respectively) and of children with defective permanent teeth (14.89 
 per cent). Upon these, pediculosis, and vaccination, the inspectors and nurses 
 very properly concentrate their attention, and under very considerable diffi¬ 
 culties, at first interposed on the part of the parents, the children, and even 
 some of the teachers, great progress has been made. This advance has been less 
 satisfactory in connection with teeth, because of lack of a sufficient number of 
 dental clinics in the schools. It is probable that many children whose parents 
 were able to afford it have been induced to consult dentists in private practice, 
 but so great was the need for treatment among children of the poorer classes 
 that the free dental clinics in connection with the dental schools of the city 
 are still unable to cope with the situation. A few dental clinics have been set 
 up in some of the schools where most needed, apparatus and services being 
 donated by dentists, and money contributed by parents’ associations and other 
 organizations. This important field of child hygiene has, however, hardly been 
 touched. 
 
 In regard to adenoids and enlarged tonsils, the school inspectors, all of whom 
 are experienced practitioners of medicine, have sustained a judicious attitude, 
 advocating removal only in those cases in which it was reasonable to think that 
 improvement would ensue. While the inspectors determined which cases should 
 seek medical or surgical attention, the ultimate decision lay with the parents 
 and the family or the dispensary physician. The small number of cases of evi¬ 
 dent tuberculosis enumerated do not represent the true number of cases of clini¬ 
 cal tuberculosis among the Baltimore school children, for the examinations 
 given are far too incomplete to lead to the discovery of any except the most ob¬ 
 vious cases. Nor does the group of mentally defective give a true picture of the 
 situation. The cases enumerated probably include only the evident idiots and 
 a certain proportion of the more backward children, for neither the inspectors 
 nor the school-teachers applied the more refined methods of diagnosis. The 
 small proportion of unvaccinated children (4.94 per cent) speaks well for the 
 success of the efforts of the health department to enforce the vaccination ordi¬ 
 nance in late years. The item “ debility ” stands for malnutrition or under¬ 
 nourishment, and, according to the reports of the inspectors, this is very 
 unevenly distributed among the schools and is largely confined to the children 
 of recent immigrants of certain race-stocks. According to the reports of the 
 inspectors and nurses, this condition among the children of the public and 
 parochial schools is due much more to lack of proper kinds and choice of foods 
 and to methods of their preparation than to lack of ability of the parents to 
 purchase food. It is of interest that, under the most important categories, the 
 
PUBLIC HEALTH ADMINISTRATION OF BALTIMORE 
 
 171 
 
 negroes compare not unfavorably with the whites, and on the whole show a 
 smaller proportion of defectives. 
 
 During the year under review there were brought to the attention of the 
 inspectors and nurses only 11 cases of the ordinary communicable diseases of 
 childhood: Mumps 8 cases, and diphtheria, measles, and chicken-pox 1 case each. 
 This emphasizes the fact that the inspection is discontinuous, the relatively 
 small inspection forces, owing to lack of time, ordinarily visiting a particular 
 school but twice a year—the second inspection to examine children absent at 
 the first. Only in exceptional instances of considerable outbreaks of diphtheria, 
 scarlet fever, measles, mumps, or chicken-pox have the school inspectors been 
 detailed thoroughly to investigate the children in particular schools for cases 
 of such diseases. In other words, the school-inspection system was not designed, 
 nor was it ever adequate, for the purpose of seeking to prevent or control out¬ 
 breaks of “ zymotic ” disease. 
 
 The school-inspection system is quite independent of the school board and 
 no reports are made to it. The board of estimates appropriates money aunually 
 to the commissioner of health for salaries for so many school inspectors or 
 school nurses, and the commissioner of health, under his general powers, insti¬ 
 tutes a system of inspection in the schools. The school board, its officers, and 
 teachers happen to be in sympathy with the movement and actively cooperate, 
 but whatever their attitude, they could at most interfere only with the smooth¬ 
 ness of the work. The inspection system has been of very great value, and that 
 it has not been of greater value is due to the fact that means have not been 
 supplied to develop the leads it has disclosed. If its only accomplishment had 
 been the supervision of vaccination enforcement it would have paid for itself 
 many times. In addition, it has resulted in ridding the school children of lice 
 and has caused great numbers of children to have their eyes, teeth, throats, and 
 noses properly cared for. Indirectly, it has resulted in cleaner and better venti¬ 
 lated and lighted schools, and the instruction of both teachers and children in 
 the elements of personal hygiene. It has gathered valuable information, on 
 which could be based a system of inspection and relief meeting the demands of 
 the local situation. 
 
 THE BUREAU OF NURSING. 
 
 The use of the trained nurse in the health department developed in a hap¬ 
 hazard manner from small beginnings. One nurse was appointed in 1905, in 
 connection with the inspection of school-children. The number was increased to 
 5 in 1906, to 10 in 1917 and to 18 in 1920. A division of tuberculosis nurses 
 was created in 1910, with 14 field nurses and a superintendent. This number 
 was raised to 16 in 1912, to 20 in 1917 and to 26 in 1920. Nurses devoted their 
 whole time to this work. 
 
 In 1917, 3 extra nurses were detailed for special services in connection with 
 cases of diphtheria, scarlet and typhoid fevers, and whooping-cough, and in 
 1919 a fourth corps of nurses was appointed to services in the bureau of mater¬ 
 nity and infant welfare. In 1918, the disciplinary and field work of the whole 
 nursing force was placed in charge of a superintendent of nurses, and in 1920 
 a separate bureau of nurses was established with a total force of 83 nurses. 
 
 12 
 
172 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 The superintendent of nurses has always directed the nursing work in con¬ 
 nection with tuberculosis, but the other nurses work under the direction of and 
 render reports to the medical officials of the various services to which they are 
 assigned. 
 
 BUREAU OF COMMUNICABLE DISEASES. 
 
 This bureau, established in 1917, has charge of the activities of the depart¬ 
 ment in respect to the supervision and restriction of persons with communicable 
 diseases, except tuberculosis. The chief of the bureau is the epidemiologist of 
 the department, receives the reports, histories, and other records of cases and 
 directs the work of the health wardens and corps of nurses, particularly in 
 regard to the isolation, hospitalization and release of cases and of contacts. 
 His services as diagnostician are available in doubtful cases. Before the estab¬ 
 lishment of this bureau these activities were supervised by the single assistant 
 commissioner of health as and when he could find time from other duties. 
 
 BUREAU OF CHILD WELFARE. 
 
 This bureau was established in 1919, and as its work is almost entirely new, 
 it can have exercised no significant influence upon morbidity and mortality 
 during the period covered in this work. Besides the oversight of midwives, 
 foundling and orphan asylums, boarding homes, and other institutions caring 
 for young children, the bureau conducts 2 obstetrical and 4 prenatal chinics and 
 a day nursery. An important feature of the work is a complete history of 
 each baby. 
 
 MISCELLANEOUS SERVICES. 
 
 For many years the city morgue, potter's field, and the city post mortem 
 physicians have been under the health department. The department has from 
 the beginning supervised the destruction of clothes, bedding, and other effects 
 of individuals with small-pox. Since 1905 a separate service has been conducted 
 for the fumigation with formaldehyde gas of houses harboring cases of pul¬ 
 monary tuberculosis, small-pox, diphtheria, and scarlet and typhus fevers, and 
 for sterilization by steam or the destruction by fire, when desired, of articles of 
 clothing and bedding after recovery or death of individuals with these diseases. 
 At various times there have been sanitary inspectors for general nuisances and 
 for tenements and boarding-houses. 
 
PART IV.—POPULATION AND STATISTICAL DATA. 
 
 Chapter VIII. 
 
 1. Population: Rate of growth; Racial composition; Distribution by 
 numbers, sex, and race. (Tables 9 to 13, graph 1.) 
 
 2. Natality: Living births; still-births. (Tables 10 to 15, 124, 126, 132.) 
 
 POPULATION. 
 
 Since the questions of the growth and racial composition of the population 
 involve factors that affected the sanitary conditions and-the variations in the 
 resistance and susceptibility of the inhabitants to certain diseases, and, in 
 
 Table 9. —Percentage of increase of total, white, and colored 'populations and proportion of 
 white and colored populations to the total population, from 1730 to 1920, inclusive. 
 
 Year. 
 
 Total popula¬ 
 tion. 
 
 White population. 
 
 Colored population. 
 
 Census count. 
 
 Percentage of 
 increase. 
 
 Census count. 
 
 Percentage of 
 increase. 
 
 Percentage to 
 total popula¬ 
 tion. 
 
 Total. 
 
 Free. 
 
 Slave. 
 
 Census 
 
 count. 
 
 Percentage 
 of increase. 
 
 Percentage 
 to total 
 population. 
 
 Census 
 
 count. 
 
 t 
 
 Percentage 
 of increase. 
 
 Percentage 
 to total 
 population. 
 
 Census 
 
 count. 
 
 Percentage 
 
 of increase. 
 
 Percentage 
 
 to total 
 population. 
 
 1730 
 
 43 
 
 
 
 
 
 
 
 
 
 
 • ••••• 
 
 
 
 
 1762 
 
 200 
 
 365 .ii 
 
 • ••••• 
 
 ...... 
 
 ...... 
 
 ...... 
 
 ...... 
 
 ...... 
 
 ...... 
 
 ...... 
 
 ...... 
 
 ...... 
 
 ...... 
 
 
 1775 
 
 6934 
 
 2867.00 
 
 • ••••• 
 
 ...... 
 
 ...... 
 
 ...... 
 
 ...... 
 
 ...... 
 
 ... 
 
 .... . . 
 
 . 
 
 ...... 
 
 . 
 
 . 
 
 1776 
 
 6765 
 
 13.84 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1790 
 
 13503 
 
 99.90 
 
 11925 
 
 
 88.31 
 
 1578 
 
 
 11.69 
 
 323 
 
 
 2.39 
 
 1255 
 
 
 9.29 
 
 1800 
 
 26514 
 
 96.36 
 
 20900 
 
 75.26 
 
 78.83 
 
 5614 
 
 255.77 
 
 21.17 
 
 2771 
 
 757.89 
 
 10.45 
 
 2843 
 
 126.63 
 
 10.72 
 
 1810 
 
 46555 
 
 75.59 
 
 36212 
 
 73.26 
 
 77.78 
 
 10343 
 
 84.24 
 
 22.22 
 
 5671 
 
 104.66 
 
 12.18 
 
 4672 
 
 64.33 
 
 10.04 
 
 1820 
 
 62738 
 
 34.76 
 
 48055 
 
 32.70 
 
 76.60 
 
 14683 
 
 41.96 
 
 23.40 
 
 10326 
 
 82.08 
 
 16.46 
 
 4367 
 
 * 6.74 
 
 6.94 
 
 1830 
 
 80625 
 
 28.61 
 
 61714 
 
 28.42 
 
 76.55 
 
 18911 
 
 28.80 
 
 23.46 
 
 14788 
 
 43.21 
 
 18.34 
 
 4123 
 
 * 5.37 
 
 5.11 
 
 1840 
 
 102313 
 
 26.90 
 
 81147 
 
 31.49 
 
 79.31 
 
 21166 
 
 11.92 
 
 20.69 
 
 17967 
 
 21.50 
 
 17.56 
 
 3199 
 
 * 22.41 
 
 3.13 
 
 1850 
 
 169054 
 
 65.23 
 
 140666 
 
 73.25 
 
 83.21 
 
 28388 
 
 34.12 
 
 16.79 
 
 25448 
 
 41.64 
 
 15.05 
 
 2940 
 
 * 8.10 
 
 1.74 
 
 1860 
 
 212418 
 
 25.65 
 
 184520 
 
 31.18 
 
 86.87 
 
 27898 
 
 * 1.73 
 
 13.13 
 
 25682 
 
 0.92 
 
 12.09 
 
 2212 
 
 * 24.76 
 
 1.04 
 
 1870 
 
 267354 
 
 25.86 
 
 227794 
 
 23.45 
 
 85.20 
 
 39560 
 
 41.80 
 
 14.80 
 
 ...... 
 
 ...... 
 
 ...... 
 
 
 ...... 
 
 ...... 
 
 1880 
 
 332313 
 
 24.30 
 
 278584 
 
 22.30 
 
 83.83 
 
 53729 
 
 35.82 
 
 16.17 
 
 ...... 
 
 
 
 
 ...... 
 
 ...... 
 
 1890 
 
 434439 
 
 30.73 
 
 367143 
 
 31.79 
 
 84.51 
 
 67296 
 
 25.25 
 
 15.49 
 
 ...... 
 
 
 
 
 ...... 
 
 ...... 
 
 1900 
 
 508957 
 
 17.15 
 
 429218 
 
 16.91 
 
 84.33 
 
 79739 
 
 18.49 
 
 15.67 
 
 ...... 
 
 ...... 
 
 ...... 
 
 
 ...... 
 
 ...... 
 
 1910 
 
 558485 
 
 9.73 
 
 473387 
 
 10.29 
 
 84.76 
 
 85098 
 
 6.72 
 
 15.24 
 
 ...... 
 
 ...... 
 
 ...... 
 
 
 
 ...... 
 
 1920 
 
 733826 
 
 31.40 
 
 625074 
 
 32.05 
 
 85.18 
 
 108752 
 
 27.80 
 
 14.82 
 
 
 . 
 
 . 
 
 
 . 
 
 ...... 
 
 * Decrease. 
 
 consequence, have exercised imporant influences upon the morbidity and mor¬ 
 tality rates, it is necessary to consider them in some detail. The essential data 
 concerning the rate of growth and the proportion of whites and negroes to the 
 total population are presented in table 9 compiled from the figures of Quinan, 
 from 1730 to 1776, and from figures obtained from the reports or from the 
 office of the Bureau of the Census, from 1790 to 1920. At the date of the first 
 census (1790), Baltimore was among the five cities of the country with over 
 8,000 population, the others being Philadelphia and suburbs (42,444), New 
 York (33,131), Boston (18,038), and Charleston (16,359). 
 
 RATE OF POPULATION INCREASE. 
 
 The history of the growth of population in Baltimore is epitomized in 
 table 9. In regard to the whole population, it is evident that immigration 
 
 173 
 
Table 10 .—The papulations specific for certain age-groups, the percentages of increase of the latter over those of the preceding decennium; 
 and the percentages of these age distributions of the respective total populations, for the census years, 1830 to 1920 inclusive.* 
 
 174 
 
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Table 10 .—The populations specific for certain age-groups, percentage of increase, etc. t—Continued. 
 
 POPULATION AND STATISTICAL DATA 
 
 175 
 
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 t The population figures in brackets for 1880 and 1890 represent graduations from the 5-year age-groupings of the Bureau of the Census for 
 those years. 
 
176 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 played a predominant role in the rate of increase, which, until 1890, far ex¬ 
 ceeded any rate possible by the natural means of excess of births over deaths. 
 With an average annual rate of increase of over 16 per cent between 1730 and 
 1752, from the latter date until 1810, the rate of growth was that of a boom 
 town—124 per cent annually from 1752 to 1775, and 9 per cent from 1775 to 
 1810. During the three decades 1810 to 1840, the average annual rate of 
 increase was less than 3 per cent. There was a sudden jump to 6.5 per cent 
 between 1840 and 1850, followed by a descent to an average annual rate of 
 about 2.7 per cent for the 40 years between 1850 and 1890. During the last 
 three decades the rate of increase was much reduced. The sharp rise in the 
 rate of increase between 1880 and 1890 was associated with a considerable 
 annexation in 1888, the only extension of the city’s boundaries since 1816. It is 
 probable that but for the influx of population in 1916-1918, due to conditions 
 arising out of the Great War and the third great annexation in 1919, the annual 
 rate of increase between 1900 and 1920 would have followed the general 
 average of less than 1 per cent, which obtained in the previous decade, when 
 for the first time in the history of Baltimore the rate of growth approached the 
 natural rate of increase, or that regulated by the increase of births over deaths. 
 
 In table 10 is given the numerical distribution by certain age-groups for 
 the total population for the census years 1830 to 1920, inclusive, together with 
 the percentage borne by each age-group to the respective totals, the percentage 
 of increase in each age-group from one decennium to the next, and the percent¬ 
 age of changes in the ratios, whether decline or increase, of population dis¬ 
 tributed by age to total population from 1850 to 1920. For the years 1850, 
 1860, 1900, 1910, and 1920 the figures for the various age-groupings are copied 
 directly from the publications of the Bureau of the Census. For the other years 
 it has been necessary to resort to graduation to obtain comparable figures for 
 certain of the age-groupings. For 1830 and 1840 it was necessary to graduate 
 the figures for the negro moiety of the population, and for 1880 and 1890 the 
 census figures given for 5-year groupings were graduated to 10-year groupings. 
 The figures for the age-groupings for 1870 were graduated throughout. These 
 data may be regarded as reasonably correct for measurement of changes in these 
 age-groupings and for the calculation of morbidity and mortality rates specific 
 for age. Of particular importance are the data concerning the proportional 
 distribution of the population below the various decades of life for the decennial 
 or census years. Attention is directed particularly to the ratios of decrease and 
 of increase in the different age-groups between 1850 and 1920 which are given 
 in the last two columns of the table. These changes, while considerable when 
 measured over this span of 70 years, were in the main gradual from one decen¬ 
 nium to the next. Their important bearing upon the interpretation of crude 
 mortality rates from all causes and upon morbidity and mortality rates from 
 specific diseases and groups of diseases is obvious. 
 
 Populations specific for the same age-groupings by color and sex for 1910 
 and 1920 are given in table 11. 
 
 In table 12, graph 1, are presented the figures for the population at all ages, 
 for total population, and for color and sex which will be used in this work for 
 the calculation of all natality, morbidity, and mortality rates except those 
 specific for age. These populations were estimated by Dr. John Bice Miner by 
 
POPULATION AND STATISTICAL DATA 
 
 177 
 
 fitting curves by the method of least squares to the populations of Baltimore at 
 the several censuses. In order to allow for the discontinuity due to the annexa¬ 
 tion of 1888, the following procedure was adopted : Before 1888 the population 
 
 Table 11.— Populations specific for certain age groupings by color and sex for 1910 and 1920. 
 
 Age period. 
 
 1910 
 
 1920 
 
 White. 
 
 Colored. 
 
 White. 
 
 Colored. 
 
 Total. 
 
 Male. 
 
 Fein. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 Total. 
 
 Male. Fem. 
 
 Under 1 year. 
 
 Between 1 and 2 years 
 
 2 to 4 years. 
 
 5 to 9 years. 
 
 0 to 9 years. 
 
 10 to 19 years. 
 
 20 to 29 years. 
 
 SO to 39 years. 
 
 40 to 49 years. 
 
 50 to 59 years. 
 
 60 to 69 years. 
 
 70 to 79 years. 
 
 80 years and over.... 
 
 Total . 
 
 8891 
 
 8485 
 
 27980 
 
 43199 
 
 88555 
 
 88989 
 
 92404 
 
 72960 
 
 57195 
 
 39054 
 
 21917 
 
 9457 
 
 2375 
 
 4489 
 
 4384 
 
 14062 
 
 21679 
 
 44614 
 
 42838 
 
 44456 
 
 35574 
 
 27564 
 
 18883 
 
 9883 
 
 3938 
 
 858 
 
 4402 
 
 4101 
 
 13918 
 
 21520 
 
 43941 
 
 46151 
 
 47948 
 
 37386 
 
 29631 
 
 20171 
 
 12034 
 
 5519 
 
 1517 
 
 1348 
 
 1127 
 
 4155 
 
 6418 
 
 13048 
 
 13771 
 
 2060 
 
 15807 
 
 11395 
 
 6063 
 
 2888 
 
 996 
 
 296 
 
 685 
 
 557 
 
 2012 
 
 3060 
 
 6314 
 
 5850 
 
 9044 
 
 7650 
 
 6655 
 
 2960 
 
 1320 
 
 403 
 
 93 
 
 663 
 
 570 
 
 2143 
 
 3358 
 
 6734 
 
 7921 
 
 11576 
 
 8157 
 
 5740 
 
 3103 
 
 1568 
 
 693 
 
 203 
 
 12884 
 
 ■ 48097 
 
 56423 
 
 117404 
 
 107776 
 
 19068 
 
 100573 
 
 76767 
 
 54705 
 
 32543 
 
 13058 
 
 3126 
 
 6600 
 
 24145 
 
 28582 
 
 59327 
 
 52818 
 
 58780 
 
 50434 
 
 38202 
 
 26684 
 
 15306 
 
 5597 
 
 1123 
 
 6284 
 
 23952 
 
 27841 
 
 58077 
 
 54958 
 
 60288 
 
 50139 
 
 38565 
 
 28021 
 
 17237 
 
 7461 
 
 2003 
 
 1968 
 
 6409 
 
 8069 
 
 16444 
 
 15954 
 
 25829 
 
 21820 
 
 15575 
 
 7858 
 
 3465 
 
 1356 
 
 354 
 
 957 
 
 3113 
 
 3861 
 
 7931 
 
 7069 
 
 12187 
 
 11053 
 
 8285 
 
 4245 
 
 1713 
 
 605 
 
 134 
 
 1011 
 
 3294 
 
 4208 
 
 8513 
 
 8885 
 
 13642 
 
 10767 
 
 7290 
 
 3613 
 
 1752 
 
 751 
 
 220 
 
 472906 
 
 228608 
 
 244298 
 
 84884 
 
 39289 
 
 45595 
 
 625020 
 
 308271 
 
 316749 
 
 108655 
 
 53222 
 
 55438 
 
 figures were taken from a logarithmic curve which fitted that portion of the 
 census figures most closely, whereas the figures for the period since 1888 were 
 taken from an autocatalytic curve (44). In this way the sudden increase in 
 the population at the annexation was satisfactorily represented. 
 
 KHZ 20 30 40 60 60 70 60 90 1900 10 20 
 
 YEARS 
 
 Graph 1 (from table 12). Estimated annual populations, in thousands, for 
 males and females, white and colored, for Baltimore from 1812 to 1920, 
 inclusive. 
 
178 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 Table 12. —Estimated population of Baltimore City, as of July 1 of each year, from 1812 
 
 to 1920, inclusive. 
 
 Year. 
 
 Total. 
 
 White. 
 
 I 
 
 Colored. 
 
 Total. 
 
 Male 
 
 Fem. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 1812 . 
 
 1 
 
 40937 
 
 20388 
 
 20549 
 
 30076 
 
 15997 
 
 14079 
 
 10861 
 
 4391 
 
 6470 
 
 1813 . 
 
 42799 
 
 21224 
 
 21575 
 
 31649 
 
 16748 
 
 14901 
 
 11150 
 
 4476 
 
 6674 
 
 1814 . 
 
 44731 
 
 22092 
 
 22639 
 
 33288 
 
 17529 
 
 15759 
 
 11443 
 
 4563 
 
 6880 
 
 1815 . 
 
 46734 
 
 22992 
 
 23742 
 
 35000 
 
 18343 
 
 16657 
 
 11734 
 
 4649 
 
 7085 
 
 1816 . 
 
 48813 
 
 23927 
 
 24886 
 
 36780 
 
 19189 
 
 17591 
 
 12033 
 
 4738 
 
 7295 
 
 1817 . 
 
 50962 
 
 24897 
 
 26065 
 
 38629 
 
 20068 
 
 18561 
 
 12333 
 
 4829 
 
 7504 
 
 1818 . 
 
 53189 
 
 25902 
 
 27287 
 
 40549 
 
 20979 
 
 19570 
 
 12640 
 
 4923 
 
 7717 
 
 1819 . 
 
 55486 
 
 26940 
 
 28546 
 
 42535 
 
 21921 
 
 20614 
 
 12951 
 
 5019 
 
 7932 
 
 1820 . 
 
 57859 
 
 28014 
 
 29845 
 
 44590 
 
 22895 
 
 21695 
 
 13269 
 
 5119 
 
 8150 
 
 1821 . 
 
 60305 
 
 29123 
 
 31182 
 
 46713 
 
 23901 
 
 22812 
 
 13592 
 
 5222 
 
 8370 
 
 1822 . 
 
 62825 
 
 30266 
 
 32559 
 
 48902 
 
 24938 
 
 23964 
 
 13923 
 
 5328 
 
 8595 
 
 1823 . 
 
 65418 
 
 31446 
 
 33972 
 
 51158 
 
 26007 
 
 25151 
 
 14260 
 
 5439 
 
 8821 
 
 1824 . 
 
 68088 
 
 32662 
 
 35426 
 
 53483 
 
 27109 
 
 26374 
 
 14605 
 
 5553 
 
 9052 
 
 1825 . 
 
 70834 
 
 33915 
 
 36919 
 
 55875 
 
 28242 
 
 27633 
 
 14959 
 
 5673 
 
 9286 
 
 1826 . 
 
 73651 
 
 35202 
 
 38449 
 
 58332 
 
 29406 
 
 28926 
 
 15319 
 
 5796 
 
 9523 
 
 1827 . 
 
 76544 
 
 36525 
 
 40019 
 
 60854 
 
 30600 
 
 30254 
 
 15690 
 
 5925 
 
 9765 
 
 1828 . 
 
 79513 
 
 37887 
 
 41626 
 
 63445 
 
 31829 
 
 31616 
 
 16068 
 
 6058 
 
 10010 
 
 1829 . 
 
 82555 
 
 39284 
 
 43271 
 
 66099 
 
 33087 
 
 33012 
 
 16456 
 
 6197 
 
 10259 
 
 1830 . 
 
 85674 
 
 40716 
 
 44958 
 
 68821 
 
 34377 
 
 34444 
 
 16853 
 
 6339 
 
 10514 
 
 1831 . 
 
 88867 
 
 42187 
 
 46680 
 
 71607 
 
 35698 
 
 35909 
 
 17260 
 
 6489 
 
 10771 
 
 1832 . 
 
 92136 
 
 43694 
 
 48442 
 
 74458 
 
 37050 
 
 37408 
 
 17678 
 
 6644 
 
 11034 
 
 1833 . 
 
 95479 
 
 45238 
 
 50241 
 
 77375 
 
 38434 
 
 38941 
 
 18104 
 
 6804 
 
 11300 
 
 1834 . 
 
 98901 
 
 46820 
 
 52081 
 
 80357 
 
 39849 
 
 40508 
 
 18544 
 
 6971 
 
 11573 
 
 1835 . 
 
 102395 
 
 48439 
 
 53956 
 
 83403 
 
 41295 
 
 42108 
 
 18992 
 
 7144 
 
 11848 
 
 1836 . 
 
 105966 
 
 50094 
 
 55872 
 
 86515 
 
 42772 
 
 43743' 
 
 19451 
 
 7322 
 
 12129 
 
 1837 . 
 
 109612 
 
 51788 
 
 57824 
 
 89691 
 
 44281 
 
 45410 
 
 19921 
 
 7507 
 
 12414 
 
 1838 . 
 
 113335 
 
 53519 
 
 59816 
 
 92932 
 
 45821 
 
 47111 
 
 20403 
 
 7698 
 
 12705 
 
 1839 . 
 
 117132 
 
 55286 
 
 61846 
 
 96237 
 
 47391 
 
 48846 
 
 20895 
 
 7895 
 
 13000 
 
 1840 . 
 
 121008 
 
 57093 
 
 63915 
 
 99608 
 
 48994 
 
 50614 
 
 21400 
 
 8099 
 
 13301 
 
 1841 . 
 
 124956 
 
 58936 
 
 66020 
 
 103041 
 
 50627 
 
 52414 
 
 21915 
 
 8309 
 
 13606 
 
 1842 . 
 
 128983 
 
 60817 
 
 68166 
 
 106539 
 
 52291 
 
 54248 
 
 22444 
 
 8526 
 
 13918 
 
 1843 . 
 
 133084 
 
 62737 
 
 70347 
 
 110102 
 
 53987 
 
 56115 
 
 22982 
 
 8750 
 
 14232 
 
 1844 . 
 
 137264 
 
 64693 
 
 72571 
 
 113729 
 
 55713 
 
 58016 
 
 23535 
 
 8980 
 
 14555 
 
 1845 . 
 
 141518 
 
 66689 
 
 74829 
 
 117420 
 
 57471 
 
 59949 
 
 24098 
 
 9218 
 
 14880 
 
 1846 . 
 
 145848 
 
 68720 
 
 77128 
 
 121174 
 
 59259 
 
 61915 
 
 24674 
 
 9461 
 
 15213 
 
 1847 . 
 
 150252 
 
 70790 
 
 79462 
 
 124991 
 
 61078 
 
 63913 
 
 25261 
 
 9712 
 
 15549 
 
 1848 . 
 
 154737 
 
 72900 
 
 81837 
 
 128874 
 
 62929 
 
 65945 
 
 25863 
 
 9971 
 
 15892 
 
 1849 . 
 
 159294 
 
 75046 
 
 84248 
 
 132820 
 
 64811 
 
 68009 
 
 26474 
 
 10235 
 
 16239 
 
 1850 . 
 
 163930 
 
 77231 
 
 86699 
 
 136829 
 
 66723 
 
 70106 
 
 27101 
 
 10508 
 
 16593 
 
 1851 . 
 
 168640 
 
 79454 
 
 89186 
 
 140902 
 
 68667 
 
 72235 
 
 27738 
 
 10787 
 
 16951 
 
 1852 . 
 
 173427 
 
 81715 
 
 91712 
 
 145037 
 
 70641 
 
 74396 
 
 28390 
 
 11074 
 
 17316 
 
 1853 . 
 
 178293 
 
 84016 
 
 94277 
 
 149239 
 
 72648 
 
 76591 
 
 29054 
 
 11368 
 
 17686 
 
 1854 . 
 
 183233 
 
 86353 
 
 96880 
 
 153502 
 
 74684 
 
 78818 
 
 29371 
 
 11669 
 
 18062 
 
 1855 . 
 
 188251 
 
 88730 
 
 99521 
 
 157829 
 
 76751 
 
 81078 
 
 30422 
 
 11979 
 
 18443 
 
 1856 . 
 
 193344 
 
 91145 
 
 102199 
 
 162219 
 
 78850 
 
 83369 
 
 31125 
 
 12295 
 
 18830 
 
 1857 . 
 
 198514 
 
 93598 
 
 104916 
 
 166672 
 
 80979 
 
 85693 
 
 31842 
 
 12619 
 
 19223 
 
 1858 . 
 
 203761 
 
 96089 
 
 107672 
 
 171188 
 
 83138 
 
 88050 
 
 32573 
 
 12951 
 
 19622 
 
 1859 . 
 
 209083 
 
 98620 
 
 110463 
 
 175768 
 
 85330 
 
 90438 
 
 33315 
 
 13290 
 
 20025 
 
 1860 . 
 
 214484 
 
 101188 
 
 113296 
 
 180411 
 
 87552 
 
 92859 
 
 34073 
 
 13636 
 
 20437 
 
 1861 . 
 
 219957 
 
 103794 
 
 116163 
 
 185115 
 
 89804 
 
 95311 
 
 34842 
 
 13990 
 
 20852 
 
 1862 . 
 
 225511 
 
 106439 
 
 119072 
 
 189884 
 
 92087 
 
 97797 
 
 35627 
 
 14352 
 
 21275 
 
 1863 . 
 
 231140 
 
 109124 
 
 122016 
 
 194716 
 
 94402 
 
 100314 
 
 36424 
 
 14722 
 
 21702 
 
 1864 . 
 
 236845 
 
 111846 
 
 124999 
 
 199611 
 
 96747 
 
 102864 
 
 37234 
 
 15099 
 
 22135 
 
 1865 . 
 
 242629 
 
 114608 
 
 128021 
 
 204570 
 
 99124 
 
 105446 
 
 38059 
 
 15484 
 
 22575 
 
 1866 . 
 
 248487 
 
 117407 
 
 131080 
 
 209589 
 
 101530 
 
 108059 
 
 38898 
 
 15877 
 
 23021 
 
POPULATION AND STATISTICAL DATA 
 
 179 
 
 Table 12.— Estimated population of Baltimore City as of July 1 of each year, from 1812 
 
 to 1920, inclusive —Continued. 
 
 Year. 
 
 Total. 
 
 White. 
 
 Colored. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 1867 . 
 
 254422 
 
 1 
 
 120246 
 
 134176 
 
 214672 
 
 103968 
 
 110704 
 
 39750 
 
 16278 
 
 23472 
 
 1868 . 
 
 260435 
 
 123122 
 
 137313 
 
 219820 
 
 106437 
 
 113383 
 
 40615 
 
 16685 
 
 23930 
 
 1869 . 
 
 266523 
 
 126039 
 
 140484 
 
 225029 
 
 108937 
 
 116092 
 
 41494 
 
 17102 
 
 24392 
 
 1870 . 
 
 272690 
 
 128993 
 
 143697 
 
 230301 
 
 111467 
 
 118834 
 
 42389 
 
 17526 
 
 24863 
 
 1871 . 
 
 278932 
 
 131987 
 
 146945 
 
 235636 
 
 114028 
 
 121608 
 
 43296 
 
 17959 
 
 25337 
 
 1872 . 
 
 285251 
 
 135018 
 
 150233 
 
 241034 
 
 116620 
 
 124414 
 
 44217 
 
 18398 
 
 25819 
 
 1873 . 
 
 291646 
 
 138089 
 
 153557 
 
 246493 
 
 119242 
 
 127251 
 
 45153 
 
 18847 
 
 26306 
 
 1874 . 
 
 298121 
 
 141200 
 
 156921 
 
 252016 
 
 121896 
 
 130120 
 
 46105 
 
 19304 
 
 26801 
 
 1875 . 
 
 304670 
 
 144348 
 
 160322 
 
 257603 
 
 124581 
 
 133022 
 
 47067 
 
 19767 
 
 27300 
 
 1876 . 
 
 311297 
 
 147536 
 
 163761 
 
 263251 
 
 127296 
 
 135955 
 
 48046 
 
 20240 
 
 27806 
 
 1877 . 
 
 318000 
 
 150762 
 
 167238 
 
 268962 
 
 130042 
 
 138920 
 
 49038 
 
 20720 
 
 28318 
 
 1878 . 
 
 324783 
 
 154028 
 
 170755 
 
 274737 
 
 132819 
 
 141918 
 
 50046 
 
 21209 
 
 28837 
 
 1879 . 
 
 331639 
 
 157333 
 
 174306 
 
 280573 
 
 135627 
 
 144946 
 
 51066 
 
 21706 
 
 29360 
 
 1880 . 
 
 338573 
 
 160675 
 
 177898 
 
 286472 
 
 138465 
 
 148007 
 
 52101 
 
 22210 
 
 29891 
 
 1881 . 
 
 345584 
 
 164057 
 
 181527 
 
 292434 
 
 141334 
 
 151100 
 
 53150 
 
 22723 
 
 30427 
 
 1882 . 
 
 352674 
 
 167479 
 
 185195 
 
 298459 
 
 144235 
 
 154224 
 
 54215 
 
 23244 
 
 30971 
 
 1883 . 
 
 359838 
 
 170938 
 
 188900 
 
 304545 
 
 147165 
 
 157380 
 
 55293 
 
 23773 
 
 31520 
 
 1884 . 
 
 367079 
 
 174437 
 
 192642 
 
 310693 
 
 150126 
 
 160567 
 
 56386 
 
 24311 
 
 32075 
 
 1885 . 
 
 374396 
 
 177974 
 
 196422 
 
 316904 
 
 153118 
 
 163786 
 
 57492 
 
 24856 
 
 32636 
 
 1886 . 
 
 381793 
 
 181551 
 
 200242 
 
 323178 
 
 156141 
 
 167037 
 
 58615 
 
 25410 
 
 33205 
 
 1887 . 
 
 389265 
 
 185167 
 
 204098 
 
 329515 
 
 159195 
 
 170320 
 
 59750 
 
 25972 
 
 33778 
 
 1888 . 
 
 419572 
 
 198102 
 
 221470 
 
 355859 
 
 170192 
 
 185667 
 
 63713 
 
 27910 
 
 35803 
 
 1889 . 
 
 427078 
 
 201823 
 
 225255 
 
 362225 
 
 173370 
 
 188855 
 
 64853 
 
 28453 
 
 36400 
 
 1890 . 
 
 434560 
 
 205547 
 
 229013 
 
 368560 
 
 176547 
 
 192013 
 
 66000 
 
 29000 
 
 37000 
 
 1891 . 
 
 442011 
 
 209271 
 
 232740 
 
 374858 
 
 179719 
 
 195139 
 
 67153 
 
 29552 
 
 37601 
 
 1892 . 
 
 449429 
 
 212994 
 
 236435 
 
 381116 
 
 182886 
 
 198230 
 
 68313 
 
 30108 
 
 38205 
 
 1893 . 
 
 456808 
 
 216714 
 
 240094 
 
 387329 
 
 186045 
 
 201284 
 
 69479 
 
 30669 
 
 38810 
 
 1894 . 
 
 464092 
 
 220426 
 
 243666 
 
 393492 
 
 189193 
 
 204299 
 
 70600 
 
 31233 
 
 39367 
 
 1895 . 
 
 471426 
 
 224129 
 
 247297 
 
 399602 
 
 192328 
 
 207274 
 
 71824 
 
 31801 
 
 40023 
 
 1896 . 
 
 478657 
 
 227822 
 
 250835 
 
 405654 
 
 195449 
 
 210205 
 
 73003 
 
 32373 
 
 40630 
 
 1897 . 
 
 485832 
 
 231501 
 
 254331 
 
 411646 
 
 198554 
 
 213092 
 
 74186 
 
 32947 
 
 41239 
 
 1898 . 
 
 492945 
 
 235164 
 
 257781 
 
 417573 
 
 201639 
 
 215934 
 
 75372 
 
 33525 
 
 41847 
 
 1899 . 
 
 500141 
 
 238810 
 
 261331 
 
 423580 
 
 204705 
 
 218975 
 
 76561 
 
 34105 
 
 42456 
 
 1900 . 
 
 506970 
 
 242435 
 
 264535 
 
 429218 
 
 207747 
 
 221471 
 
 77752 
 
 34688 
 
 43064 
 
 1901 . 
 
 513875 
 
 246038 
 
 267832 
 
 434930 
 
 210765 
 
 224165 
 
 78945 
 
 35273 
 
 43672 
 
 1902 . 
 
 520706 
 
 249619 
 
 271087 
 
 440566 
 
 213758 
 
 226808 
 
 80140 
 
 35861 
 
 44279 
 
 1903 . 
 
 527456 
 
 253172 
 
 274284 
 
 446121 
 
 216722 
 
 229399 
 
 81335 
 
 36450 
 
 44885 
 
 1904 . 
 
 534122 
 
 256697 
 
 277425 
 
 451593 
 
 219657 
 
 231936 
 
 82529 
 
 37040 
 
 45489 
 
 1905 . 
 
 540705 
 
 260193 
 
 280512 
 
 456981 
 
 222561 
 
 234420 
 
 83724 
 
 37632 
 
 46092 
 
 1906 . 
 
 547212 
 
 263667 
 
 283545 
 
 462284 
 
 225433 
 
 236851 
 
 84928 
 
 38234 
 
 46694 
 
 1907 . 
 
 553609 
 
 267090 
 
 286519 
 
 467497 
 
 228271 
 
 239226 
 
 86112 
 
 38819 
 
 47293 
 
 1908 . 
 
 559924 
 
 270487 
 
 289437 
 
 472620 
 
 231073 
 
 241547 
 
 87304 
 
 39414 
 
 47890 
 
 1909 . 
 
 566145 
 
 273848 
 
 292297 
 
 477653 
 
 233840 
 
 243813 
 
 88492 
 
 40008 
 
 48484 
 
 1910 . 
 
 572269 
 
 277170 
 
 295099 
 
 482591 
 
 236568 
 
 246023 
 
 89678 
 
 40602 
 
 49076 
 
 1911 . 
 
 578297 
 
 280455 
 
 297842 
 
 487436 
 
 239258 
 
 248178 
 
 90861 
 
 41197 
 
 49664 
 
 1912 . 
 
 584227 
 
 283698 
 
 300529 
 
 492187 
 
 241908 
 
 250279 
 
 92040 
 
 41790 
 
 50250 
 
 1913 . 
 
 590056 
 
 286900 
 
 303156 
 
 496841 
 
 244517 
 
 252324 
 
 93215 
 
 42383 
 
 50832 
 
 1914 . 
 
 595785 
 
 290060 
 
 305725 
 
 501400 
 
 247085 
 
 254315 
 
 94385 
 
 42975 
 
 51410 
 
 1915 . 
 
 601413 
 
 293176 
 
 308237 
 
 505863 
 
 249611 
 
 256252 
 
 95550 
 
 43565 
 
 51985 
 
 1916 . 
 
 606937 
 
 296247 
 
 310690 
 
 510228 
 
 252093 
 
 258135 
 
 96709 
 
 44154 
 
 52555 
 
 1917 . 
 
 612360 
 
 299273 
 
 313087 
 
 514497 
 
 254532 
 
 259965 
 
 97863 
 
 44741 
 
 53122 
 
 1918 . 
 
 617680 
 
 302254 
 
 315426 
 
 518671 
 
 256928 
 
 261743 
 
 99009 
 
 45326 
 
 53683 
 
 1919 . 
 
 721192 
 
 355107 
 
 366085 
 
 616912 
 
 307237 
 
 309675 
 
 104280 
 
 47870 
 
 56410 
 
 1920 . 
 
 1 
 
 733826 
 
 361611 
 
 372215 
 
 625074 
 
 308340 
 
 316734 
 
 108752 
 
 53271 
 
 55481 
 
180 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 RACIAL COMPOSITION OF THE POPULATION—WHITE. 
 
 As in the colony of Maryland, so in early Baltimore, the bulk of the white 
 population was of English, Welsh, or Scotch descent. In the earliest records of 
 Baltimore Town, English surnames were predominant in number, with a 
 sprinkling of Scotch and Irish. Many of those bearing Scotch names are known 
 to have immigrated from the north of Ireland and have often been erroneously 
 classed as of Irish stock. According to the United States census of 1790, the 
 208,604 white inhabitants of Maryland, classified according to blood or nation¬ 
 ality strain, as determined by their surnames, were: English 84 per cent, Scotch 
 6.5 per cent, Irish 2.4 per cent, German 5.9 per cent, French 0.7 per cent, 
 Hebrew 0.3 per cent, Dutch 0.1 per cent, all other 0.1 per cent. While it is 
 probable that the population of Baltimore was at that time distributed racially 
 in very much the same proportions, it is likely that the proportions for Germans 
 and for Dutch would be too high and those for French and Jews too low, for 
 it can safely be assumed that most of the people with German and Dutch names 
 in Maryland had settled in the counties bordering on the Pennsylvania line, 
 that the considerable French colony would have attracted many of their asso¬ 
 ciates to the town, and that nearly all of the Jews would have settled in the 
 largest trading town of the State. As would be expected, the proportion of 
 people of British extraction—English, Welsh, and Scotch—was largely pre¬ 
 dominant, and that for this and for other reasons they put their stamp indelibly 
 upon the life and characteristics of the town and city. 
 
 Owing to the incompleteness and the vagaries of the reports on population 
 issued by the Bureau of the Census, it is impossible to determine with any satis¬ 
 factory degree of accuracy the numbers and proportions of any of the various 
 stocks of the white race in Baltimore for the different census years since 1790. 
 No information at all on this point appears before 1860. However, from 
 figures giving the number of foreign-born from various countries for 1860, 
 1870, and 1880, and for the number of foreign-born of various countries and 
 of native-born of such parents (the immigrant and first generation in Balti¬ 
 more) for 1890, 1900, and 1910, it has been possible to make estimates of the 
 actual numbers of representatives of certain prominent race stocks in the 
 population as of 1910. Since in the first three of these decennia no mention 
 is made of any but the first generation—the immigrant, and in the last three 
 decennia all except the first two generations—the immigrant and the first 
 generation born in this country—are ignored in the census reports, the 
 resulting estimates may be regarded as only rough approximations to the truth. 
 The results are further complicated by the fact that, for the most part, the 
 immigrants were classified geographically, and considerable difficulty has 
 attended the extraction of Jews from Germany and Austria from ethnological 
 Germans, and Poles and Bohemians from Austro-Germans, who in turn must 
 be classed with Germans. As British have been classed all immigrants from 
 British colonies and dominions (except French Canadians), as well as those 
 from England, Wales, and Scotland. To save space, the essential facts selected 
 from an elaborate compilation of data have been condensed into table 13, 
 showing the numbers and percentages contributed by each important race- 
 stock in the population as of 1910. On the basis of these two estimates and 
 with the aid of pertinent facts supplied by local chroniclers, the history of the 
 growth of each of the important white race-stocks will be traced in. 
 
POPULATION - AND STATISTICAL DATA 
 
 181 
 
 The British element has received additions from three sources by migrants; 
 directly from England, Wales, Scotland, and Ireland, especially numerous just 
 before and after the War of the Revolution and after the Napoleonic Wars; 
 from British colonies, particularly Canada and the West Indies; and from 
 Maryland and other colonies and States as Americans of British descent. Of 
 these groups, the last is the most important. Members of this group were 
 derived especially from New England, New York, New Jersey, Delaware, 
 Pennsylvania, Virginia, and North Carolina, and, to a less degree, in later 
 years, from western States and States farther south. These people, represent¬ 
 ing the best development of the British stock in this country, and imbued with 
 the spirit of adventure, were by far the most important additions gained by 
 migration. The influx beginning just before 1776 was particularly strong until 
 about 1840, and, while no definite figures can be given, it seems certain that 
 the larger proportion of these people were contributed by New England, Mary- 
 
 Table 13. — Population. 
 
 Stock. 
 
 Population. 
 
 Percentage of 
 population of speci¬ 
 fied race stock to 
 total white 
 population. 
 
 British . 
 
 160000 
 
 33.70 
 
 German . 
 
 132000 
 
 27.80 
 
 Irish . 
 
 62500 
 
 13.16 
 
 Jewish . 
 
 50000 
 
 10.53 
 
 Polish . 
 
 22000 
 
 4.63 
 
 Bohemian . 
 
 10000 
 
 2.11 
 
 Italian . 
 
 10000 
 
 2.11 
 
 French . 
 
 8000 
 
 1.68 
 
 Unimportant . 
 
 20319 
 
 4.28 
 
 Total white population. 
 
 474819 
 
 100.00 
 
 land, and Virginia. After the Civil War there was a particularly heavy migra¬ 
 tion of people from Virginia and North Carolina. Fusing readily with the 
 local population, the migrants from all these States assumed leading roles in 
 thought, education, commerce, finance, and the professions. It is probable that 
 from 1815 until 1860 there was a considerable migration to Baltimore of 
 Britons from the mother country and from the colonies. The census figures 
 from 1860 show a comparatively small but steadily increasing immigration 
 from these sources, the British-born numbering 2,925 in 1860, 3,141 in 1870, 
 3,448 in 1880, 3,637 in 1890, 4,182 in 1900, and 4,087 in 1910. This stock, 
 always the most numerous single stock forming the bulk of the white population 
 before 1830, probably remained in the majority until after the Civil War. 
 In 1910, estimated at 160,000, it formed 33 per cent. In point of time, due 
 to the migrations of Acadians in 1755 and of the French from San Domingo, 
 people of French extraction composed the most numerous non-British element. 
 The first French immigrants, whose exact number is unknown, were sufficiently 
 numerous to have the name “ French Town ” given to the quarter in which 
 they were settled, and must have formed, for a time at least, one-fourth of the 
 
182 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 population of Baltimore Town. They were notably industrious and frugal, 
 and many of them turned to ship-building. The second migration, comprising 
 3,000, and including an unknown number of negro slaves, left San Domingo in 
 consequence of the revolution and reached Baltimore in 1793. Many of them 
 were people of property, education, and talent, and soon took a leading part in 
 the business, professional, social, and religious life of the community. Some 
 of the most distinguished families of present-day Baltimore trace their ancestry 
 to these immigrants. In 1794 probably 20 per cent of the white population was 
 of French blood. Immigration of the French since 1793 has been small and 
 intermittent, and it is unlikely that there were more than 8,000 people of 
 French blood in Baltimore in 1910. 
 
 The relation of the Irish to Baltimore is of peculiar interest and impor¬ 
 tance. While many, both Protestant and Catholic, came to the Maryland 
 colony, at one period the migration of the latter was discouraged by a discrim¬ 
 inatory tax. Though the land upon which Baltimore Town was laid out was 
 purchased from the prominent land-owning Catholic Carroll family, members 
 of which were early identified with the town, it does not appear that any con¬ 
 siderable proportion of the early inhabitants were of this origin. The Catholic 
 Irish, who really represent the distinctively Irish race, had become sufficiently 
 numerous by the last of the eighteenth century to play an important part in 
 the social, commercial, and professional life of the town, and their influence 
 has continually grown. To what extent this portion of the population was 
 recruited from the counties of Maryland, from other colonies or States, and 
 by direct migration from Ireland it is not possible to state with exactness. 
 Certain it is that after the peace of 1815, there began a steady stream of migra¬ 
 tion of Catholic Irish from Ireland to Baltimore, which, assuming large pro¬ 
 portions in the third and fourth decades of the nineteenth century, reached its 
 high point in the fifth decade, and, continuing at a slower rate until 1870, had 
 practically died out in 1890. According to the census reports, there were 
 recorded in Baltimore as born in Ireland 15,511 persons in 1860, 15,223 in 
 1870, 14,238 in 1880, 13,659 in 1890, 9,690 in 1900, and 6,806 in 1910. Of 
 Irish birth and native-born of Irish parentage, there were 38,051 in 1890, 
 33,100 in 1900, and 27,465 in 1910. From these figures it would appear that in 
 1910 there were not far from 62,500 persons of Irish Catholic stock in Balti¬ 
 more. The Protestant Irish, some bearing names suggestive of English origin 
 but most of them evidently of Scotch extraction, have been included among the 
 British. They have taken throughout the history of the city a leading part and 
 have exercised an influence out of proportion to their number. The Stevenson 
 brothers, Henry, the leading physician of his day, and John, the founder of 
 Baltimore’s commerce, arrived in 1745. 
 
 The Germans came to Baltimore early, the first arriving in 1752 from Lan¬ 
 caster, Pennsylvania. Dr. Charles Wiessenthal, the accomplished physician 
 and Eevolutionary patriot, came in 1755. The Germans were sufficiently nu¬ 
 merous to establish a Lutheran Church in 1758 and in 1790 probably exceeded 
 800. The Germans, mostly from the Palatinate, of the early migration took 
 a prominent part in the town and city and soon merged into the general popu¬ 
 lation by both association and marriage. The later accessions came in greatest 
 numbers from Prussia, Saxony, Wurttemburg, Hanover, and Austria. Bremen 
 
POPULATION AND STATISTICAL DATA 
 
 183 
 
 enjoyed a large commerce with Baltimore by 1830, and during the third, fourth, 
 fifth, sixth, and seventh decades of the nineteenth century there was a strong tide 
 of German immigration to Baltimore. The peak of the German migration was 
 some 10 or 15 years later than that of the Irish. The number of German-born 
 in Baltimore was 32,608 in 1860, 35,491 in 1870, 34,337 in 1880, 40,480 in 
 1890, 34,564 in 1900, and 25,104 in 1910. The German-born and native-born 
 of German parentage numbered 111,172 in 1890 and declined to 94,002 in 
 1910. All these figures, however, include German Jews. If 100,000 be taken 
 as the approximate number of German-born and native children of true Ger¬ 
 man stock in 1890, it is probable that in 1910 the whole number of representa¬ 
 tives of this stock in Baltimore was not far from 132,000. 
 
 The early Jewish settlers in Baltimore probably came from Holland and 
 England, for several Jewish families of distinction, belonging to the well- 
 known group of “Spanish” Jews, prominent in the Netherlands since 1492 
 and later in England, settled in Baltimore at an early date. With this excep¬ 
 tion the Jewish immigrants to Baltimore, until about 1884, came almost 
 entirely from the German states and bear typically German names. This immi¬ 
 gration probably began after 1830 and practically ceased with 1870. The total 
 Jewish population of Baltimore was estimated in 1880 as about 10,000 by 
 Dr. Aaron Eriedenwald, a distinguished physician and publicist of that race. 
 With additions from other parts of this country and by natural increase, German 
 Jews probably numbered 20,000 by 1910. A third immigration of Jews, result¬ 
 ing in a population which can be measured with a considerable degree of ac¬ 
 curacy, began about 1884 from Russian Poland, in consequence of religious and 
 social persecution. The foreign-born Polish Jews, numbering 179 in 1880, 
 increased to 4,118 in 1890, 10,509 in 1900, and 15,585 in 1910, and the number 
 of native-born of such parentage (first generation) increased from 1,435 in 
 1890 to 11,557 in 1910. Since in the latter year the combined figure for 
 foreign-born and the first generation of descendants was 27,142, it is likely 
 that 30,000 is a fair estimate of the total number of Polish Jews at that date. 
 Therefore, the whole number of persons of Jewish stock in Baltimore in 1910 
 may be reckoned as 50,000. 
 
 A stream of emigrants from southern and southeastern Europe started about 
 1870. Weak at first, it had reached considerable proportions by 1910. In order 
 of their arrival were the Bohemians, who in 1910 numbered 7,750 as foreign- 
 born and as first-generation native-born, with a probable total of 10,000. The 
 Italian migration, starting about 1870, first from northern but later almost 
 entirely from southern Italy and Sicily and gradually increasing, resulted in 
 the presence of 8,540 persons of foreign birth and natives of the first generation, 
 with a probable total of 10,000 of this stock in 1910. In addition, small numbers 
 of people of diverse stocks have come from Hungary, Greece, Bulgaria, Serbia, 
 Roumania, and Turkey. 
 
 From the north of Europe a migration of Poles started about 1870, reached 
 considerable size by 1900, and by 1910 there were 11,123 foreign-born and 
 10,476 native-born of the first generation, with a probable total of 22,000. In 
 the last decade of the nineteenth and the first decade of the twentieth century 
 a small number of Lithuanians, Letts, Russians, and Finns entered. From time 
 to time there have come, within the last 50 years, a small number of persons 
 
184 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 from Scandinavia, Belgium, Holland, Switzerland, Spain, Portugal, and other 
 countries of Europe and from South America. The total of these races, together 
 with immigrants from southern Europe, other than Italians and Bohemians, 
 represent the group of numerically unimportant stocks in the table, estimated 
 to number 20,319 in 1910. 
 
 The percentages of actual foreign-born whites to the total whites for the 
 decennia from 1860 to 1910, inclusive, were 28.35, 24.70, 20.10, 18.60, 15.97, 
 and 16.24, respectively. 
 
 From the foregoing it is especially to be noted that the basic race stock of 
 Baltimore, those of British ancestry descended largely from English, Welsh, 
 and Scotch who settled in the colonies or in the States of the United States 
 before 1820, has been the predominant stock numerically. Until 1870 it must 
 have comprised considerably over 50 per cent of the white population. 
 
 Up until 1880 the white population consisted almost exclusively of people of 
 British, German, Irish, French, and Jewish stocks, with the first three very 
 largely in excess, who had been in association through many years. The first- 
 named four of these, though divided to some degree by relatively minor differ¬ 
 ences, had long since become fused into a compact citizenship in business and 
 social life and even in intermarriage. Since 1880, new and important racial fac¬ 
 tors have been added by the arrival of Poles, Polish Jews, Bohemians, Italians, 
 Lithuanians, and others, who have preserved the habits, customs, languages, 
 and racial prejudices peculiar to themselves and which have tended to cut them 
 off from each other and from the rest of the population. To a very large degree 
 they live in colonies and work and worship in racial groups. 
 
 POPULATION GROWTH—COLORED. 
 
 Since at no time in the history of Baltimore have Indians and Mongolians 
 been numerous, the term colored has meant persons of African negro blood, 
 either pure or in various degrees of admixture with white blood; hence, for 
 convenience, here as elsewhere in this work, the word negro will be used for 
 colored. There exist no reliable figures for the negro population of Baltimore 
 before the census of 1790. The rate of increase in the decade 1790-1800 was 
 high, averaging over 25 per cent per annum, continuing at a relatively high level 
 for the next decade, and descending irregularly until there was an actual loss 
 in population in the sixth decade. There was a decided rise between 1860 and 
 1870, then the rate of increase fell consistently during the following four 
 decades. Between 1910 and 1920 there was a marked increase. Notwithstand¬ 
 ing these wide fluctuations in the rate of increase, between 1800 and 1840 the 
 percentage of negroes to the total population varied within narrow limits, the 
 average being about 22 per cent; after dropping during the sixth decade of the 
 nineteenth century to 13 per cent, it gradually rose, so that from 1870 to 1920 
 it stood close to 15.5 per cent. Since the birth-rate of the negro in Baltimore 
 has probably never approached his death-rate, for any length of time at least, 
 it is evident that his growth in population has been determined almost, if not 
 entirely, by immigration. This immigration has doubtless been governed by 
 demands for laborers and domestic servants. Whereas the number and percent¬ 
 age of slave negroes increased from 1790 to 1810, after the latter date there 
 was a gradual decrease, until by 1860 they numbered less than in 1800. In 
 
POPULATION AND STATISTICAL DATA 
 
 185 
 
 1860 they formed only 1 per cent of the population and 8 per cent of the 
 negroes. It is evident that conditions in Baltimore were not favorable to negro 
 slavery. On the other hand, the city has had strong attractions for negro immi¬ 
 grants who have come particularly from the States of Maryland, Virginia, 
 North Carolina, and Georgia. 
 
 NATALITY. 
 
 LIVING BIRTHS. 
 
 No record of living births was kept until 1875, when by law it became the 
 duty of physicians and midwives to report them. Before 1912 the health 
 department made no consistent efforts to enforce this law, and it was not until 
 1915 that Baltimore was included among the birth-registration cities. Data 
 for the live births recorded annually between 1875 and 1920 and their ratios 
 to the total population and to whites and negroes separately are given in 
 table 14. It is evident from these figures that birth registration was very defec¬ 
 tive until 1915. In the whole population the recorded live birth-rate exceeded 
 the death-rate, in but 12 of the 46 years between 1875 and 1920, and in only 
 7 of the 40 years previous to 1914. In the 37 years between 1884 and 1920, the 
 official birth-rate surpassed the death-rate in whites in only 19 years and in 
 negroes in only 2 years. The death-rate exceeded the recorded birth-rate among 
 whites in each year between 1898 and 1911, inclusive. Since 1912 the birth¬ 
 rate has been well above the death-rate in this section of the population. Among 
 negroes this discrepancy between birth and death rates obtained in every year 
 for which birth records exist, except in 1919 and 1920, when the death-rates 
 were unusually low and the birth-rates were the highest recorded. Since 1883 
 in only one year, 1918, can this excess of deaths over births so frequently 
 recorded be attributed to a severe epidemic. For the six-year period 1915-1920, 
 during which it may be held that live births were reported with approximate 
 completeness, the average annual birth and death rates per 1,000 living popu¬ 
 lation were for whites, 24.43 and 16.50 and for negroes 24.62 and 28.43, 
 respectively. When 1918, the influenza year, with its exceptionally heavy 
 mortality, is left out of consideration, the respective rates were 24.32 and 
 15.05, and 24.87 and 26.60. Therefore, in recent years, on an average for each 
 1,000 inhabitants among whites the excess in births over deaths was 9, while 
 among negroes there was an excess of 1.7 in deaths over births, or, in other 
 words annually, by this means, the whites increased by almost 1 per cent and 
 the negroes decreased by 0.17 per cent. 
 
 The vital index, i. e., the percentage of births to deaths, proposed by 
 Pearl (45) as a delicate test in the study of population growth, may be used 
 conveniently here to measure the accuracy of reporting of living births. The 
 vital indices for the total population for whites and for negroes are presented 
 in table 14. It will be observed that for the population as a whole the vital 
 index exceeded 100 in only 7 years between 1875 and 1914, and in only 4 years 
 before 1912. During the whole period from 1895 to 1912, when the recorded 
 birth-rate was always below 20 per 1,000, in but 3 years did the vital index 
 exceed 90. Among whites, while between 1884 and 1894 the birth-rate was 
 always between 20 and 22 per 1,000, the vital index was, with the exception of 
 
186 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 Table 14. — Number of recorded births, living and still, percentage of still to total births, 
 and rates, per 100,000 living inhabitants, and vital indices for the whole population 
 and for white and colored, from 1875 to 1920, inclusive. 
 
 Year. 
 
 Total. 
 
 births. 
 
 Still 
 
 births. 
 
 Per 
 cent 
 of still 
 births 
 tototal 
 births. 
 
 Living births. 
 
 Total. 
 
 White. 
 
 Colored. 
 
 No. 
 
 Rate. 
 
 Vital 
 
 in¬ 
 
 dex. 
 
 No. 
 
 Rate. 
 
 Vital 
 
 in¬ 
 
 dex*. 
 
 No. 
 
 Rate. 
 
 Vital 
 
 in¬ 
 
 dex. 
 
 1875 
 
 
 8735 
 
 560 
 
 6.4 
 
 8175 
 
 2683 
 
 112.6 
 
 
 
 
 
 
 
 1876 
 
 
 7838 
 
 588 
 
 7.5 
 
 7250 
 
 2329 
 
 96.7 
 
 
 
 
 
 
 
 1877 
 
 
 7146 
 
 538 
 
 7.5 
 
 6608 
 
 2078 
 
 83.5 
 
 
 
 
 
 
 
 1878 
 
 
 6715 
 
 655 
 
 9.8 
 
 6060 
 
 1866 
 
 90.0 
 
 
 
 
 
 
 
 1879 
 
 
 8227 
 
 620 
 
 7 5 
 
 7607 
 
 2294 
 
 99.9 
 
 
 
 
 
 
 
 1880 
 
 
 9462 
 
 636 
 
 6.7 
 
 8826 
 
 2607 
 
 109.7 
 
 . 
 
 
 
 
 
 
 1881 
 
 
 9158 
 
 651 
 
 7 1 
 
 8507 
 
 2462 
 
 96.5 
 
 
 
 
 
 
 
 1882 
 
 
 8436 
 
 677 
 
 8.0 
 
 7759 
 
 2200 
 
 86.9 
 
 . 
 
 . 
 
 . 
 
 
 
 
 
 1883 
 
 
 8605 
 
 701 
 
 8.1 
 
 7904 
 
 2197 
 
 84.3 
 
 
 
 
 
 
 
 1884 
 
 • • 
 
 8881 
 
 746 
 
 8.4 
 
 8025 
 
 2186 
 
 96.8 
 
 6889 
 
 2217 
 
 107.7 
 
 1136 
 
 2015 
 
 59.9 
 
 1885 
 
 • • 
 
 8390 
 
 650 
 
 7.7 
 
 7740 
 
 2067 
 
 94.9 
 
 6632 
 
 2093 
 
 104.9 
 
 1108 
 
 1927 
 
 60.6 
 
 1886 
 
 * # 
 
 8415 
 
 718 
 
 8.5 
 
 7694 
 
 2015 
 
 92.3 
 
 6481 
 
 2005 
 
 100.1 
 
 1213 
 
 2069 
 
 65.1 
 
 1887 
 
 • • 
 
 9726 
 
 699 
 
 7.2 
 
 9027 
 
 2319 
 
 107.8 
 
 7765 
 
 2356 
 
 121.7 
 
 1262 
 
 2112 
 
 63.4 
 
 1888 
 
 • • 
 
 9419 
 
 694 
 
 7.4 
 
 8725 
 
 2079 
 
 97.6 
 
 7500 
 
 2108 
 
 108.8 
 
 1225 
 
 1923 
 
 60.0 
 
 1889 
 
 • • 
 
 10149 
 
 784 
 
 7.7 
 
 9365 
 
 2193 
 
 107.6 
 
 8102 
 
 2237 
 
 118.8 
 
 1263 
 
 1947 
 
 67.0 
 
 1890 
 
 
 10198 
 
 800 
 
 7.8 
 
 9398 
 
 2163 
 
 92.2 
 
 8226 
 
 2232 
 
 102.5 
 
 1172 
 
 1776 
 
 54.0 
 
 1891 
 
 • • 
 
 10150 
 
 811 
 
 8.0 
 
 9339 
 
 2113 
 
 92.7 
 
 8238 
 
 2198 
 
 105.1 
 
 1101 
 
 1640 
 
 49.3 
 
 1892 
 
 • • 
 
 10247 
 
 813 
 
 7.9 
 
 9434 
 
 2099 
 
 89.2 
 
 8087 
 
 2122 
 
 96.7 
 
 1347 
 
 1972 
 
 60.6 
 
 1893 
 
 • • 
 
 9905 
 
 770 
 
 7.8 
 
 9135 
 
 2000 
 
 95.6 
 
 7914 
 
 2043 
 
 107.4 
 
 1221 
 
 1757 
 
 55.9 
 
 1894 
 
 • • 
 
 10104 
 
 721 
 
 7.1 
 
 9383 
 
 2022 
 
 98.9 
 
 8030 
 
 2041 
 
 110.9 
 
 1353 
 
 1916 
 
 60.3 
 
 1895 
 
 • • 
 
 8725 
 
 666 
 
 7.6 
 
 8059 
 
 1709 
 
 78.2 
 
 7667 
 
 1919 
 
 97.2 
 
 1392 
 
 1938 
 
 57.6 
 
 1896 
 
 • • 
 
 9472 
 
 678 
 
 7.2 
 
 8794 
 
 1837 
 
 88.7 
 
 7495 
 
 1848 
 
 98.5 
 
 1299 
 
 1779 
 
 56.3 
 
 1897 
 
 • • 
 
 9506 
 
 706 
 
 7.4 
 
 8800 
 
 1811 
 
 94.3 
 
 7382 
 
 1793 
 
 103.1 
 
 1418 
 
 1911 
 
 65.5 
 
 1898 
 
 • • 
 
 9541 
 
 748 
 
 7.8 
 
 8793 
 
 1784 
 
 84.7 
 
 7227 
 
 1731 
 
 91.4 
 
 1566 
 
 2078 
 
 63.2 
 
 1899 
 
 • • 
 
 8739 
 
 701 
 
 8.0 
 
 8038 
 
 1607 
 
 79.2 
 
 6796 
 
 1604 
 
 87.5 
 
 1242 
 
 1622 
 
 52.0 
 
 1900 
 
 • • 
 
 9335 
 
 682 
 
 7.3 
 
 8653 
 
 1707 
 
 80.9 
 
 7242 
 
 1687 
 
 89.5 
 
 1411 
 
 1815 
 
 54.1 
 
 1901 
 
 • • 
 
 9467 
 
 672 
 
 7.1 
 
 8795 
 
 1712> 
 
 83.9 
 
 7125 
 
 1638 
 
 90.7 
 
 1670 
 
 2115 
 
 63.7 
 
 1902 
 
 • • 
 
 9609 
 
 659 
 
 6.9 
 
 8950 
 
 1719 
 
 87.3 
 
 7193 
 
 1633 
 
 93.0 
 
 1757 
 
 2192 
 
 69.7 
 
 1903 
 
 • • 
 
 9361 
 
 741 
 
 7.9 
 
 8620 
 
 1634 
 
 85.0 
 
 7001 
 
 1569 
 
 91.4 
 
 1619 
 
 1991 
 
 65.2 
 
 1904 
 
 • • 
 
 9309 
 
 710 
 
 7.6 
 
 8599 
 
 1610 
 
 79.5 
 
 6863 
 
 1520 
 
 84.7 
 
 1736 
 
 2104 
 
 63.9 
 
 1905 
 
 • • 
 
 9765 
 
 814 
 
 8.3 
 
 8951 
 
 1655 
 
 83.7 
 
 7077 
 
 1549 
 
 89.1 
 
 1874 
 
 2238 
 
 68.0 
 
 1906 
 
 • • 
 
 9928 
 
 826 
 
 8.3 
 
 9102 
 
 1663 
 
 84.6 
 
 7300 
 
 1579 
 
 90.9 
 
 1802 
 
 2122 
 
 66.3 
 
 1907 
 
 • • 
 
 9555 
 
 794 
 
 8.3 
 
 7861 
 
 1583 
 
 78.3 
 
 7128 
 
 1525 
 
 85.1 
 
 1633 
 
 1896 
 
 58.1 
 
 1908 
 
 • • 
 
 9989 
 
 811 
 
 8.1 
 
 9178 
 
 1639 
 
 88.0 
 
 7564 
 
 1600 
 
 96.1 
 
 1614 
 
 1849 
 
 63.0 
 
 1909 
 
 • • 
 
 9613 
 
 817 
 
 8.5 
 
 8796 
 
 1554 
 
 84.8 
 
 7313 
 
 1531 
 
 93.9 
 
 1483 
 
 1676 
 
 57.4 
 
 1910 
 
 • • 
 
 10680 
 
 822 
 
 7.7 
 
 9858 
 
 1723 
 
 91.7 
 
 7941 
 
 1645 
 
 97.5 
 
 1917 
 
 2138 
 
 73.5 
 
 1911 
 
 • • 
 
 9995 
 
 712 
 
 7.1 
 
 9283 
 
 1605 
 
 89.2 
 
 7592 
 
 1558 
 
 97.8 
 
 1691 
 
 1861 
 
 63.9 
 
 1912 
 
 • • 
 
 12087 
 
 689 
 
 5.7 
 
 11398, 
 
 1951 
 
 109.2 
 
 9387 
 
 1907 
 
 119.1 
 
 2011 
 
 2185 
 
 78.5 
 
 1913 
 
 • • 
 
 13451 
 
 909 
 
 6.8 
 
 12542 
 
 2126 
 
 123.3 
 
 10309 
 
 2075 
 
 131.3 
 
 2233 
 
 2396 
 
 96.3 
 
 1914 
 
 • • 
 
 13663 
 
 1026 
 
 7.5 
 
 12637 
 
 2121 
 
 119.8 
 
 10665 
 
 2127 
 
 134.8 
 
 1972 
 
 2089 
 
 74.8 
 
 1915 
 
 • • 
 
 14765 
 
 1131 
 
 7.7 
 
 13634 
 
 2267 
 
 136.3 
 
 11460 
 
 2265 
 
 152.3 
 
 2174 
 
 2275 
 
 87.8 
 
 1916 
 
 # # 
 
 16320 
 
 1235 
 
 7.6 
 
 15085 
 
 2485 
 
 140.7 
 
 12662 
 
 2482 
 
 158.6 
 
 2423 
 
 2505 
 
 88.6 
 
 1917 
 
 • • 
 
 16217 
 
 1267 
 
 7.8 
 
 14950 
 
 2441 
 
 131.6 
 
 12582 
 
 2445 
 
 150.5 
 
 2368 
 
 2420 
 
 78.9 
 
 1918 
 
 • • 
 
 16492 
 
 1200 
 
 7.3 
 
 15292 
 
 2476 
 
 95.4 
 
 12975 
 
 2502 
 
 105.4 
 
 2317 
 
 2340 
 
 62.3 
 
 1919 
 
 • • 
 
 18958 
 
 1327 
 
 7.0 
 
 17631 
 
 2445 
 
 154.2 
 
 14908 
 
 2417 
 
 167.7 
 
 2723 
 
 2611 
 
 107.0 
 
 1920 
 
 • • 
 
 20185 
 
 1398 
 
 6.9 
 
 18787 
 
 2560 
 
 165.4 
 
 15934 
 
 2549 
 
 181.5 
 
 2853 
 
 2623 
 
 110.7 
 
POPULATION AND STATISTICAL DATA 
 
 187 
 
 a single year, invariably above 100, from 1895 to 1912, with birth-rates con¬ 
 sistently below 20, the vital index was under par in every year except 2. With 
 the increase in the recorded birth-rate after 1915, the vital index for whites 
 rose to levels characteristic for a population growing rapidly by excess of 
 births over deaths. Between 1884 and 1911 the vital index for negroes was 
 commonly below 60 and never exceeded 70, but in one year. It is true that for 
 the negro, with the high death-rate that existed during all these years, a birth¬ 
 rate of well over 30 per 1,000 population would have been necessary for a vital 
 index of 100. It was not until the considerable fall in the death-rate, togetner 
 with the rise in the recorded birth-rate, that the vital index for this race rose 
 above 100. The conclusion is inevitable that until 1916 the reporting of live 
 births was far from complete in both races, and that the losses in population 
 presaged by the official figures were apparent and not real. 
 
 It is not possible from the data at hand to estimate with any accuracy the 
 probable birth-rates for the white and negro populations previous to 1916. 
 It is probable, however, that since 1812, the white live birth-rate has rarely if 
 ever fallen below 20 and has often been higher than 30 per 1,000 inhabi¬ 
 tants. It is reasonably certain that during this period, except in connection 
 with unusually severe epidemics, there has been for this race a comfortable 
 annual surplus of live births over deaths, which would have insured a steady 
 but moderate increase of population independent of immigration. It is likely 
 that on the whole the live birth-rate has been higher in the negro than in the 
 white race. With his much higher death-rates, however, only in exceptional 
 years could the births have exceeded the deaths in this race. It follows, then, 
 that by and large the white population has undergone a healthy natural increase 
 and that the negro population has not been self-sustaining in the same sense, 
 and its actual increase has been due entirely to immigration. 
 
 Data regarding the relative frequency of legitimate and illegitimate births 
 and their distribution by color and sex, available since 1900, are presented in 
 table 15. Of the whole number of living births reported within these periods, 
 6.6 per cent were illegitimate. The proportions of illegitimacy among whites 
 and negroes were 3.1 per cent and 23.8 per cent, respectively. The proportion 
 of males to females was, for total births, among whites as 1.06 to 1 and among 
 negroes, as 1.05 to 1, and for illegitimate births 1.04 to 1 among whites and 
 1.004 to 1 among negroes. 
 
 STILL-BIRTHS. 
 
 Still-births have been recorded in the statistical tables in every year since 
 1812, but not until 1900 were they classified according to sex and color. The 
 recorded data concerning still-births are presented in tables 132, 14, 15, and 
 126. Nowhere in the records is still-birth defined. It is unlikely that whatever 
 definition custom had established was seriously modified, except under very 
 unusual circumstances. It is probable, therefore, that on the whole until 
 very recent years, a still-birth represented a dead-born fetus of at least 5 full 
 months of utero-gestation. During the last 10 years, due partly to the pressure 
 of the administrative authorities and partly to the request of the department 
 of anatomy of the Johns Hopkins Medical School, physicians have become 
 accustomed to reporting some fetuses of much earlier stages of development. 
 
 13 
 
Table 15. —Number of total, illegitimate and still-births by color and sex, from 1900 to 1920, inclusive. 
 
 188 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
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POPULATION AND STATISTICAL DATA 
 
 189 
 
 As, with this exception, both before and after 1875, when death and birth 
 certificates were first required, the only reason for reporting still-births would 
 have been to escape charges of infanticide and to secure burial, it is reasonable 
 to suppose that the registration of births of dead-born fetuses was limited to 
 those near or well above viable size and age, i. e., of at least the stage of develop¬ 
 ment compatible with extra-uterine survival of live : born fetuses. 
 
 Since for every locality there is generally a very definite relation between the 
 number of live and still births, the proportion of still-births may be expected 
 to fluctuate with the birth-rate, i. e., the proportion of live-born chidren. This 
 has probably varied within wide limits in Baltimore as elsewhere. Another 
 factor of recognized importance, but one which can not be measured here with 
 any degree of exactness, is the variation in the character of obstetrical care and 
 of the inherent maternal qualities of the women. Finally, there must be taken 
 into account the variations in the prevalence of certain general and local dis¬ 
 eases which are known to be fatal to fetuses, such as small-pox, influenza, 
 pneumonia, yellow, typhus, and typhoid fevers, syphilis, and gonorrhoea. 
 
 In the absence of specific information regarding the true live birth-rate 
 previous to 1916, the frequency of still-births can only be estimated by round¬ 
 about methods. From table 132, it will be observed that the rates for recorded 
 still-births as calculated on the basis of the whole population show very wide 
 fluctuations over much of the 109-year period for which they may be followed. 
 The highest and lowest rates recorded were 276 in 1812, and 102 in 1862. The 
 rates declined, but in a rather irregular fashion, from 1812 to 1828, when the 
 low level of 113 was reached. This was a period of heavy mortality from 
 malarial, yellow, and typhus fevers and pneumonia, all of which had fallen 
 considerably by 1828. During this period, in connection with the financial 
 depression following the war, the total birth-rate probably declined sharply. 
 The gradual, but somewhat irregular rise in the rates from 1829 to 1847, when 
 the rate stood between 240 and 258 for this and the next 3 years, and the 
 succeeding decline during the following 12 years to 102 in 1862, suggest a 
 corresponding rise and fall in the birth-rate. The low still-birth rate during 
 and immediately following the Civil War suggests that the total birth-rate 
 declined materially in this period. By 1870 the still-birth rate had risen to 194. 
 The sharp decline in 1873 and 1874 may have been associated with a fall in 
 total birth-rate under the influence of the small-pox epidemic of this time. 
 From 1875 to 1892 the rate for still-births was comparatively high and varied 
 within rather narrow limits. During the period from 1895 to 1915 of very low 
 recorded live-birth rates already alluded to, the still-birth rates were corre¬ 
 spondingly low. While this correspondence was perhaps due to low actual birth¬ 
 rates, it is more than likely that the meager rates were in both cases the direct 
 result of poor registration. It is to be noted that the rates for still-births rose 
 after 1912 and by 1915 had reached the level of 1875-1892, which was main¬ 
 tained from 1916 to 1920. From table 14 it appears that from 1875 to 1920 
 the ratio of still to the total recorded births, both live and still, varied but 
 slightly from year to year. When the still-birth rate (table 132) is compared 
 with the death-rate for women in child-birth (table 124), both calculated on 
 the basis per 100,000 population, it is found that, with a few notable exceptions, 
 the two rates rose and fell together. These correspondences suggest very 
 
190 PUBLIC HEALTH ADMINISTKATIOX, ETC., IN BALTIMOBE 
 
 strongly that during the period in which live births have been reported, on an 
 average, whether reporting was complete or incomplete, the registration of still 
 and live births has been maintained at about the same ratio. 
 
 During the whole period since 1875 the proportion of still to total reported 
 births has been unusually high, well over 7 per cent. The more exact registra¬ 
 tion of the last few years gave results not far different, the average for the 
 6-year period 1915-1920 being 7.4 per cent. For 1919 and 1920 the ratios were 
 5.9 per cent for whites and 12.8 per cent for negroes. As it is improbable that 
 these proportions have varied widely, it is safe to assume that these remarkably 
 high ratios of still to total births have obtained constantly in Baltimore. From 
 the data compiled in table 15, it is evident that a much larger proportion of 
 still-born fetuses were of the male than of the female sex, the ratios being 1.55 
 to 1 for whites and 1.35 to 1 for negroes. 
 
Chapter IX. —Statistical Material. 
 
 Character; Sources; Uses; Methods. 
 
 In the annual reports of the health department, which are preserved since 
 1827 in continuous series, there are given the amounts of money appropriated 
 for expenses. In the early reports, the appropriations and expenditures are 
 given under separate headings for office administration, salaries of commis¬ 
 sioners and clerks, for the quarantine office and station, for the control of 
 nuisances, and for the removal of garbage and the cleaning of streets. As the 
 department expanded after 1870, it is possible to trace and to separate with 
 some degree of accuracy the sums spent on certain activities in connection with 
 attempts to control some of the diseases amenable either to general or 
 specific measures, as for instance, small-pox, tuberculosis, or the communicable 
 diseases as a group, by fumigations, the health warden system, etc. It is 
 possible to find the sums appropriated for the divisions of chemistry, bacteri- 
 ology, plumbing, or nursing, for example, for terms of years. However, when 
 it comes to the evaluation of any of these activities by themselves, or in groups, 
 it is practically impossible to obtain information sufficiently definite to mean 
 anything when expressed in terms of disease control. 
 
 Taking garbage removal as an illustration of a public-health service: In the 
 first place, it was sometimes done by contract, sometimes by laborers appointed 
 by the health department, and sometimes, as after 1882, by a separate depart¬ 
 ment of the city government; in the second place, this function has been 
 inseparably bound up with the cleaning of streets, and from time to time 
 with the cleaning of sewers. The problems of garbage removal, of street 
 cleaning, and of sewer cleaning have varied widely at different periods in the 
 history of the city; the purchasing value of money has also been subject to 
 considerable changes. 
 
 If it is sought to estimate the influence of money spent upon the control of 
 the communicable diseases as a group, the sums of the appropriations for the 
 laboratories, the health wardens, fumigation and disinfection, the small isola¬ 
 tion hospital and the quarantine station, the nursing and plumbing divisions, 
 and school inspection would not include the whole amount so spent, and com¬ 
 parisons of the per capita cost with the death-rates from these diseases would 
 not bear any accurate relation to each other. 
 
 It is not possible to determine the sums expended on water supplies and 
 service, nor to apportion the huge sums invested during late years in the con¬ 
 struction and maintenance of a double system of sewers; nor can any correct 
 estimate be made of the cost borne by householders in connecting properties 
 with these sewers. No one who is acquainted with what is known of the history 
 of these matters would attribute any value to such comparisons. All that can be 
 done intelligently in this direction is to attempt in the proper places in relation 
 to the discussion of the courses of certain groups of diseases to picture the con¬ 
 ditions obtaining and the specific actions of the health department aimed at 
 
 191 
 
192 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 their control at different times. What is wanted in this connection is knowl¬ 
 edge of conditions and actions and not inaccurate guesses at the amount 
 of money appropriated at particular times for indefinite services. It is certain 
 that sums appropriated have ever fallen short of the desires and recommenda¬ 
 tions of the health authorities, and that, in many instances, the city authorities 
 exercised good judgment in this respect. 
 
 STATISTICAL NOSOLOGY. 
 
 The early statistical nosology was primitive and, as in the old London Bills 
 of Mortality, the deaths were classified in alphabetical order by names of 
 diseases or of prominent symptoms without regard to anatomical, causal, or 
 other relationships, except in the case of fevers, under which heading were 
 grouped together in alphabetical sequence some of the prominent affections of 
 which fever is a conspicuous symptom. This method is well illustrated in the 
 following copy of the list of interments for 1819: 
 
 List of interments for 1819. 
 
 Abscess . 1 Hives . 
 
 Apoplexy . 21 Jaundice . 
 
 Asthma . 5 Intemperance . 
 
 Burn . 2 Insanity .. 
 
 Cancer . 4 Inflammation of stomach. 
 
 Casualty . 17 Inflammation of lungs. 
 
 Childbed . 18 Inflammation of bowels. 
 
 Cholera morbus . 125 Inflammation of brain. 
 
 Cholic . 4 Lockjaw . 
 
 Consumption . 272 Measles . 
 
 Convulsions . 89 Mortification . 
 
 Cramp in stomach. 3 Murdered . 
 
 Croup . 57 Old age . 
 
 Decay . 88 Palsy . 
 
 Dropsay . 41 Pleurisy . 
 
 Do. in the head. 27 Rheumatism . 
 
 Drowned . 31 Scrofula . 
 
 Dysentery . 21 Small-pox . 
 
 Epilepsy . 4 Sore throat . 
 
 Fever . 4 Spasm . 
 
 bilious . 73 Still-born . 
 
 inflammatory . 2 Sudden death . 
 
 intermittent . 4 Do. by drinking cold water 
 
 malignant . 350 Suicide . 
 
 nervous . 2 Syphilis . 
 
 remittent . 2 Teething . 
 
 typhus . 84 Whooping-cough . 
 
 Flux . 5 Worms . 
 
 Fistula . 1 Unknown . 
 
 Gravel . 3 
 
 Gout . 1 Total . 
 
 Haemorrhage . 3 
 
 Under 1 year. 
 
 Between 1 and 2 years 
 Between 2 and 5 years 
 Between 5 and 10 years 
 Between 10 and 20 years 
 Between 20 and 30 years 
 Between 30 and 40 years 
 Between 40 and 50 years 
 
 51G Between 50 and 60 years 
 
 252 Between 60 and 70 years 
 
 129 Between 70 and 80 years 
 
 147 Between 80 and 90 years 
 
 291 Between 90 and 100 years 
 
 357 Over 100 years. 
 
 191 Still-born . 
 
 117 
 
 There were 1,716 white deaths and 571 colored deaths. 
 
 3 
 
 2 
 
 46 
 
 1 
 
 1 
 
 29 
 
 1 
 
 10 
 
 2 
 
 116 
 
 26 
 
 7 
 
 77 
 
 7 
 41 
 
 5 
 
 2 
 
 1 
 
 11 
 
 3 
 
 105 
 
 16 
 
 8 
 3 
 3 
 
 27 
 
 78 
 59 
 91 
 
 2,287 
 
 71 
 
 39 
 
 35 
 
 27 
 
 9 
 
 1 
 
 105 
 
POPULATION AND STATISTICAL DATA 
 
 193 
 
 The first indication of an anatomical grouping appeared when, under inflam¬ 
 mations, those affecting different organs were grouped together in alphabetical 
 order. This innovation was quite illogical in certain respects, for only a part of 
 the so-called inflammatory diseases were thus treated and no distinction was 
 drawn between acute and chronic affections. The terms inflammation of the 
 lungs, peripneumonia, and pleurisy all may appear in the same table. Acute 
 rheumatism, a febrile and inflammatory affection, was not included under 
 either fevers or inflammation of joints, but appeared as a separate rubic. 
 Abscess also appeared under a separate heading. Scarlet fever was classified 
 with fevers, and measles, mumps, small-pox, and chicken-pox were not. Organic 
 diseases of the heart and angina pectoris were separated by the distance of 
 their initial letters. Cirrhosis of the liver could not be distinguished from 
 abscess of this organ, and abscess of the liver might be hidden under abscess 
 or under inflammation of the liver. This crude nosology admitted of no study 
 of the relative frequency of deaths due to diseases of various organs. The 
 number of items in the list was gradually expanded so that by 1850 they num¬ 
 bered 95; in 1863 they had contracted to 83; there were 106 in 1873, 108 in 
 1880, 268 in 1890, and 323 in 1898. This expansion was brought about partly 
 by distribution of certain affections among the various organs, as congestion, 
 hemorrhage, abscess, tuberculosis, cancer, tumor, and stone, and by the separa¬ 
 tion of acute and chronic diseases of certain organs, as the brain, liver, and 
 kidneys. Nephritis first appeared in 1850 and diabetes in 1851. This crude 
 form of classifying deaths has imposed great labor and care in the compilation 
 of the figures for the different causes of death that it is possible to separate 
 out and trace through the whole period. In the early reports a considerable 
 number of deaths were unclassified, being grouped under “ causes unknown.” 
 As late as 1837, 529 deaths were so grouped, of which 519 were “ infantile.” 
 Fortunately, the great mass of the deaths assigned to “ causes unknown ” were 
 in infants, probably recently born for the most part, so that the figures for such 
 diseases as pulmonary tuberculosis, the exanthematous diseases, and other 
 affections which caused the death of older children and adults were not seri¬ 
 ously affected by this circumstance. With the introduction of death certificates 
 in 1875, the number of deaths attributed to “ causes unknown ” greatly 
 decreased. 
 
 In the classification of deaths in the annual list of deaths by causes, the offi¬ 
 cials of the Baltimore health department were completely oblivious to the prog¬ 
 ress made elsewhere, especially in England, Switzerland, France, and Sweden, 
 under the influence of Farr, D’Espine, Bertillon, and others, and in this country 
 by the committee of the American Medical Association in 1847. Joynes in 
 1850 (46) and Charles Frick in 1855 (47), in analyzing the deaths in Balti¬ 
 more classified them according to the latter system, which was evidently largely 
 copied from Farr’s, but the force of inertia in the health department was not 
 overcome until 1900. In this year there was a. complete change in the statisti¬ 
 cal nosology, modified from the Bertillon classification, under 15 headings: 
 (1) Epidemic diseases; (2) general diseases, containing a curious mixture; 
 (3) diseases of the nervous system; (4) diseases of the circulatory system; 
 (5) diseases of the respiratory system; (6) diseases of the digestive system; 
 (7) diseases of the genito-urinary system; (8) diseases of the puerperal state; 
 (9) diseases of the skin and cellular tissue; (10) diseases of the locomotor 
 
194 PUBLIC PIEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 system; (11) malformations; (12) diseases of infancy; (13) affections of 
 old age; (14) deaths due to violence; (15) causes ill defined. The rubrics were 
 not numbered. In 1902, the first two headings were combined under general 
 diseases. The international classification of the causes of death was adopted in 
 1903, with the causes of death under 189 headings. 
 
 REPORTS OF DEATHS. 
 
 Records of deaths have been collected and compiled by the health department 
 since 179?. The annual reports, first issued in 1817, have contained a list of 
 deaths by causes, but with the exception of the report for 1819 preserved in 
 the library of the Medical and Chirurgical Faculty of Maryland, none are 
 available before 1827. Since the latter date the files are complete, those between 
 1827 and 1849 having been collected and bound in a single volume in the 
 City Library, and those for 1850 and succeeding years are in the health depart¬ 
 ment. Owing to the fortunate circumstance that weekly and annual tables of 
 interment from 1812 to 1832 are to be found in the files of the Baltimore 
 American and Commercial Advertiser, it has been possible to follow the record 
 back to 1812. Since these data correspond in number and classification with 
 those of the annual reports for 1819 and 1827-1832, and with those published 
 from time to time in the Weekly Register by Niles and Russ, they may be 
 regarded as official. The records of the deaths, therefore, are available in 
 unbroken series since 1812. 
 
 Before death certificates were required by law in 1875, the tables of inter¬ 
 ments were compiled from weekly reports made to the health department by 
 the sextons of the cemeteries. The records of the sextons were apparently com¬ 
 plete and faithful in regard to color, sex, and age, for even the early tables give 
 data for these. Concerning the causes of death they are less trustworthy, and 
 the number classed as due to “ causes unknown,” in both infants and adults, 
 forms a large proportion in the tables for the early years. 
 
 There is no record of the employment of official searchers to ascertain the 
 causes of death. The cemeteries were either within the city limits or conveni¬ 
 ently near. Only when a body was removed to a distance for burial is it probable 
 that the record of the death was missed. Wynne, writing in 1849, expressed the 
 opinion that most of the deaths were returned and that the tables were sub¬ 
 stantially correct in regard to numbers. As previously stated, the deaths of those 
 dying at the almshouse and at the almshouse hospital, the quarantine (in¬ 
 cluding the so-called marine) hospital, and later the Sydenham Hospital, 
 were not included among the city deaths. These comprised a not inconsider¬ 
 able number. Since 1900, deaths at the almshouse or Bayview Hospital and 
 Sydenham Hospital have been so included. The deaths among the insane and 
 the tuberculous residents of the city dying at State and private hospitals and 
 sanatoria without the city are not transferred, but are charged against the 
 counties in which these institutions are located. At the sanatoria for the tuber¬ 
 culous, the deaths of city residents have averaged about 125 annually since 
 1913. Until 1856, the still-born were included with the deaths, but as a separate 
 item. 
 
 From the beginning, the reports contained tables giving the number of 
 deaths from all causes by age of decedents, as under 1 year, between 1 to 2 
 
POPULATION AND STATISTICAL DATA 
 
 195 
 
 years, 2 to 5 years, 5 to 10 years, and thereafter decennially. The deaths 
 are classified by race for white and colored (colored divided into free and slave), 
 and by sex for the total. It is not possible to determine with accuracy the 
 number of deaths by color and sex until 1857, because, before that date, 
 m the special tables of deaths for color and sex as set up, still-births were 
 included and males and females were not separated as to color. Therefore, 
 until 1857, the rates for white and colored as calculated in the tables presented 
 are of necessity based upon figures for deaths inclusive of still-births. In the 
 early years the deaths of colored free and slaves were not classified by sex. Since 
 1857, deaths from all causes are classified by sex and color in correlated form. 
 It has not been possible to obtain any of the original reports of the sextons to 
 the health department. 
 
 The form of death certificate first in use after the law of 1875 called for the 
 name, address, age, sex, race (white or colored), birthplace, duration of illness, 
 cause of death, and signature of the attending physician. Since deaths recorded 
 in 1874 and 1875 show no considerable variation in number, either for all 
 causes or for the more important causes of death, it is likely that under the 
 previous system not many deaths within the city were unrecorded. With the 
 passage of time, the information required on the death certificates was made 
 more comprehensive, and in 1899 the standard death certificate was adopted. 
 
 STATISTICAL STUDIES RELATING TO CAUSES OF DEATH. 
 
 It is notable that though in the early reports attention is directed from time 
 to time to an unusually large number of deaths ascribed to some particular 
 diseases, such as cholera, yellow fever, small-pox, typhus fever, measles, scarlet 
 fever, or to the high mortality of infants, it was not until 1875 that any real 
 use was made of statistical methods in the Baltimore health department to 
 determine the relative importance of different diseases as causes of death, and 
 only in occasional years were even the crude death-rates calculated. This 
 omission is the more curious because Wynne in 1849, Levin S. Joynes in 1850, 
 and Charles Frick in 1855 published interesting studies of mortality in Balti¬ 
 more, in relation to age, sex, and race, and discussed in an enlightened manner 
 the relation of various diseases and disease groups to the annual mortality. 
 
 Crude mortality-rates for deaths from all causes appear annually in the 
 reports since 1875. In this year, Commissioner Steuart compared the rates for 
 Baltimore with those of some 40 other cities, and in 1879 he compiled a table 
 of the annual mortality rates for 1873 to 1879 and discussed some of the chief 
 contributory factors. However, in these discussions, as well as those of succeed¬ 
 ing years until 1916, with certain notable exceptions to be reviewed later, 
 reported cases and deaths of particular diseases were recorded only in absolute 
 figures and not in relation to numbers actually exposed. 
 
 From 1883, the reports abound in statistical tables of the causes of death. 
 The earliest gives annually from 1830 to 1883 the total deaths from all causes, 
 total deaths under 5 years of age, and the total deaths from “ zymotic diseases,” 
 with the percentage of deaths of children under 5 years to the total deaths. 
 In 1884, tables were introduced giving the total number of deaths by months 
 in each ward; the weekly deaths from pulmonary tuberculosis by color and 
 sex from 1875; the annual mortality rates from all causes and from pulmonary 
 
196 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 tuberculosis, according to race (white and colored) and sex from 1875 to 1884, 
 with the mean temperature and humidity of the atmosphere; a comparative 
 table of the deaths from all causes and for pulmonary tuberculosis among 
 males and females, white and colored for the 10-year period; tables of the 
 number of deaths in each ward for each week in 1884 from pneumonia, pul¬ 
 monary tuberculosis, and from the various “ zymotic diseases.” 
 
 In the next year these tables were supplemented by one giving the number 
 of deaths from cancer from 1830 to 1884, inclusive. Additional tables were 
 presented in 1886 and in the years immediately succeeding, giving the annual 
 number of deaths since 1875 from typhoid fever as occurring among males, 
 females, native and foreign white, and colored; the number of deaths from 25 
 “ zymotic 99 diseases in each ward by months; the total number of deaths in 
 each ward, according to sex, nativity, and race; and the deaths by occupation 
 of the decedents. 
 
 The report for 1888 carried an interesting chart, giving annually the number 
 of deaths from cholera infantum in children under 5 years of age from 1830 
 to 1888, inclusive, and a similar one for scarlet fever and for small-pox. In 
 this year the commissioner of health, reviewing the mortality from “ zymotic 99 
 diseases, pointed out that the percentage of deaths from these diseases to the 
 total mortality from all causes had fallen from the average of 28 per cent 
 during the 48 years from 1836 to 1883 to an average of 22 per cent for the 
 5-year period, 1884 to 1888. For certain specific diseases, the drop in the 
 average annual number of deaths was as follows: Scarlet fever from 227 to 57; 
 diphtheria (14 years from 1870 to 1883) from 469 to 143; typhoid fever (24 
 years from 1860 to 1883) from 190 to 155. These or similar tables, in which 
 total mortality or mortality from separate diseases or disease groups are com¬ 
 pared, almost invariably in absolute figures of the numbers of deaths, are 
 features of the health department reports to the present day. 
 
 Since 1903, the reports have been supplemented by other raw-data tables, 
 dealing with diphtheria, scarlet fever, measles, whooping-cough, gastro-enteritis 
 in children, lobar- and broncho-pneumonia and bronchitis, pulmonary and other 
 forms of tuberculosis, chronic nephritis, organic diseases of the heart, and 
 cancer. In these tables are given the absolute number of deaths, mostly 
 by age, sex, color, occupation, and ward, but, since for any particular disease, 
 the data are distributed over at least three tables and arranged in each 
 separate table in relation to only two or at most three categories, the material 
 is relatively useless for comparative study. From some of these tables, however, 
 it is possible to arrange new tables from which there may be calculated, for the 
 census year 1910, rates specific in regard to age, sex, and color, for certain 
 affections. 
 
 Between 1903 and 1915, Dr. C. Hampson Jones made interesting compara¬ 
 tive studies, using sometimes rates and sometimes absolute figures, of certain 
 principal causes of death, notably of tuberculosis, typhoid fever, pneumonia, 
 diarrhoea and enteritis in children, Bright’s disease, and organic heart disease, 
 in relation to age, sex, and color. 
 
 In the annual summary of vital statistics, which for many years has been 
 given in connection with the mortality tables, only the births and total deaths 
 are expressed in rates, the deaths from prominent communicable and other 
 important affections being given only in absolute figures. 
 
POPULATION AND STATISTICAL DATA 
 
 197 
 
 RECORDS OF MORBIDITY. 
 
 Records of morbidity are scanty and incomplete before 1898. In years of 
 severe epidemics of yellow fever, cholera, and small-pox, some reports of the 
 number and distribution of cases were obtained, but it is doubtful if these were 
 ever complete. Quinan chronicled the figures for cases of small-pox during 
 some of the early epidemics. In the reports of the consulting physician, or of 
 the president of the board of health, in the earlier years, the absence or presence 
 of cases of small-pox, of cholera, or of .yellow fever are often noted. Even in 
 the extensive epidemic of small-pox in 1872-1873, though cases were searched 
 out by the police and health wardens, and physicians reported cases voluntarily, 
 the annual reports fail to record the number of cases. In the report for 1882 
 it is stated that 4,000 cases of small-pox were discovered in 1872, and that 
 probably an equal number of cases were concealed. It can not be said that 
 there were any morbidity statistics, even for small-pox, in the Baltimore health 
 department until 1882. Not until after 1894 was there any serious effort made 
 to record data for and to utilize morbidity statistics in the health department. 
 Between 1898 and 1915, Dr. Jones used morbidity data in the study of typhoid 
 fever, and Dr. Stokes, in his annual reports, used morbidity rates in his studies 
 of the influence of diphtheria antitoxin and the diphtheria-culture test upon 
 the prevalence of diphtheria, and of the relation of water and milk to typhoid 
 fever. It can not be said, however, that before 1916 any attempt was made 
 to apply data of morbidity routinely to problems of public-health administra¬ 
 tion in Baltimore. 
 
 The reporting of communicable diseases, with the exception of pulmonary 
 tuberculosis, measles, mumps, and whooping-cough, has been fairly full and 
 accurate since 1898, and the data for all of the reportable diseases has been 
 compiled by weeks and months since this date. 
 
 The annual reports of the quarantine officer, since 1832, contain tables giving 
 the numbers of cases and deaths at the station. Many of these included, of 
 course, individuals sent from the city ill with small-pox and typhus fever. 
 
 The extensive tables of defects found in routine examinations of school 
 children by the medical inspectors and published annually since 1907 present 
 the data in absolute figures only. 
 
 STATISTICAL METHOD. 
 
 Unless indicated otherwise, all rates for natality, mortality, and morbidity 
 presented in this work are calculated on the basis of 100,000 living population. 
 Decimal fractions 5 and over have been absorbed by the whole number and those 
 below 5 have been disregarded. As they are commonly without significance, 
 with few exceptions, rates amounting to less than 1 per 100,000 have not been 
 entered iu the statistical tables. For convenience in typography, the initial 
 letters C, D, and R are used to signify the words case, death, and rate in the 
 tables of morbidity and mortality. Rates for the total population and those 
 specific for color and sex are calculated on the populations in table 12, and 
 those specific for age, color, and sex on the populations in tables 10 and 11. 
 Certain rates for deaths under 1 year and for maternal morbidity are based 
 on data of table 14. Unless otherwise indicated, the rubric numbers referred to 
 in the text are those of the international classification of the Causes of Death, 
 revision of 1909. 
 
PART V.—THE FEBRILE DISEASES. 
 Chapter X. —Nuisance Diseases. 
 
 1. Insect-borne diseases: Malaria; Yellow fever; Typhus fever. (Tables 
 16, 18, graphs 2-4.) 
 
 2. Acute inflammatory affections of the intestinal tract characterized 
 by frequent loose stools of abnormal composition: Diarrhoea; Dysentery; 
 Asiatic cholera; Typhoid fever. (Tables 19 to 33, graphs 5 to 10.) 
 
 INSECT-BOENE DISEASES. 
 
 Of the diseases spread from man to man through the media of biting or 
 stinging insect hosts as vectors, malarial, yellow, and typhus fevers are the 
 only ones of practical importance in Baltimore. Only one death, in 1879, has 
 been recorded from relapsing fever, and bubonic pest, trypanosomiasis, and 
 other diseases of this class have never been recognized in Baltimore. 
 
 MALARIAL FEVERS. 
 
 Malaria was common in Maryland for many years before Baltimore was 
 founded, but very little information exists concerning the prevalence and 
 severity of the malarial diseases in Baltimore Town before 1794, and then they 
 are mentioned only incidentally in connection with yellow fever as perennially 
 present, in varying intensity in the summer and fall, particularly along the 
 water-front, and especially at FelFs Point. Davidge, Reese, Coulter, Potter, 
 and others in their reports and other writings on yellow fever, between 1798 
 and 1821, constantly referred to the “ common intermittent, remittent, and 
 bilious remittent fevers,” associated often with dysentery and present every 
 year at FelPs Point and along Jones Falls. They attributed these fevers to 
 noxious vapors arising from decaying vegetable material in the numerous 
 ditches, ponds, pools, and dock-slips at FelFs Point and in the basin and in 
 the marshes along the latter and Jones Falls and Harford Run. 
 
 These annual summer and fall fevers, either intermittent or remittent in 
 type, varied much in severity not only from year to year but in any particular 
 season, and were described as being of a much more severe type in the late 
 summer and early fall than in June, when they made their first appearance. 
 Yellow discoloration of the skin and vomiting of bile (or broken-down blood 
 mistaken for bile) were common characteristics of the remittent form so com¬ 
 monly termed “ bilious fever.” These characteristics caused this type of 
 malarial fever to be confused in certain years with true yellow fever, which 
 even so good an observer as Davidge held to be only an accentuation of the 
 familiar bilious remittent. From the descriptions of the intermittent and of 
 the usual remittent fevers, as well as from their successful treatment with 
 preparations of cinchona bark, it is fair to conclude that these fevers were for 
 the most part true malaria. That bilious or bilious remittent fever was a 
 synonym for remittent malarial fever appears certain from the writings of 
 Davidge, Potter, Bartlett (48), and Jameson (49). The latter described an 
 epidemic of bilious remittent fever, occurring in 1804, that was successfully 
 curbed by treatment with “ the bark.” 
 
 199 
 
200 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 The great expansion of ocean commerce between Baltimore and the West 
 Indies, after the Revolutionary War, and later with the Southern States and 
 with South America, must have insured the annual importation of cases of 
 the severer grades of tropical and subtropical malaria, from which infection 
 was spread by mosquitoes abounding at Fell’s Point and the lower-lying 
 sections about the basin and the streams flowing into it. The topography of 
 the city and the imperfect drainage, due to the poor grading, pavements, and 
 gutters, afforded abundant opportunities for large and small mosquito-breeding 
 pools. The standing water in many cellars furnished another set of breeding 
 places. According to the annual health report for 1824, there was a marked 
 decrease in autumnal sickness in the neighborhood of Eden Street and Harford 
 Run after filling in and running a drain which did away with standing water, 
 and it was noted that the “ French drains ” constructed in various parts of 
 FelPs Point acted well and the inhabitants suffered much less with autumnal 
 fever than in the preceding fall. 
 
 In his work on epidemic cholera at the Baltimore almshouse in 1849, Thomas 
 H. Buckler (11) gave a map (2) of the medical topography of Baltimore in 
 1851, on which the whole territory south and southeast and west of the city 
 bordering on the Patapsco River, Curtis Bay, and the middle branch is marked 
 “ Region of intermittent and remittent fever.” The northern limit of this area 
 was bounded by the “ mine banks,” or iron-ore deposits; on the west side it 
 followed the general course of the Baltimore and Ohio Railroad, and on the east 
 side the Philadelphia Turnpike, just north of the Baltimore, Wilmington, and 
 Philadelphia Railroad. At the almshouse, situated to the west of the northern 
 border of the city, “ intermittent and remittent bilious fevers were spontaneous 
 in their origin (among the inmates) almost every season, while the country for 
 a mile or two around enjoyed a comparative immunity from these affections. 
 Besides the indigenous origin of malarious fevers, a very large number of inter- 
 mittents are brought in every season, and also remittents, in the autumn of 
 some years, from the iron-ore mine-banks, of the Washington and Philadelphia 
 Roads.” That the remittent fever of this period at the almshouse was continuous 
 malarial fever is attested by the notes of William T. Howard, sr., a medical 
 resident there in 1843, in which was recorded a clear-cut clinical history of a 
 fatal case with a full autopsy protocol of a man from the “ mine bank.” This 
 case was also reported by Swett (50) of Hew York. Anderson and Prick (51), 
 resident physicians at the almshouse during the summer of 1844, autopsied 12 
 cases of remittent fever, which were analyzed by Alfred Stille in 1845. Ten 
 of these 12 cases came from the mine-banks. Buckler recorded that in 1851 a 
 grave epidemic of intermittent and remittent fevers prevailed, as a new feature 
 of the medical history of this locality, on both sides of Jones Falls, north of 
 Centre Street, and at the Maryland Penitentiary. The outbreak of malarial 
 fevers in this locality was attributed by Buckler to the vast quantities of filth 
 in the bed of the falls, the stream of which was rendered sluggish in the dry 
 season by the diversion of so large a proportion of its water to supply the 
 reservoir, situated above at the Belvedere Bridge. That malarial fevers were 
 rife between 1870 and 1885 at Fell’s Point and along the uncovered portions 
 of Harford Run, in the northwestern section of the city, is evident from the 
 text of the reports of the commissioners of health. Dr. Alexander C. Abbott 
 is authority for the statement that in the latter area between 1870 and 1880 
 
FEBRILE DISEASES 
 
 201 
 
 large numbers of newly built houses were vacated by their tenants because of 
 the great prevalence of severe malarial fever. Between 1889 and 1895, many 
 individuals with malaria living in various parts of the city, and from the 
 surrounding territory on or near the water, particularly at Sparrow’s Point, 
 applied to the dispensaries of the Maryland University and Johns Hopkins 
 Hospital. At Bayview Asylum the experience of the former almshouse was 
 repeated between 1866 and 1900. 
 
 There is no doubt that from its early history until about 1895 malarial 
 fevers were very prevalent in and around Baltimore; within the city its chief 
 prevalence was about the harbor, docks, basin, Jones Falls, Harford Run, and 
 probably along the courses of Schroeder’s and Chatworth’s Runs. In these 
 portions of the city conditions were particularly favorable for mosquito breeding, 
 not only because of standing water in and about docks, in streams and marshes, 
 and in the streets, gutters, alleys, and yards of low-lying valleys, but in cellars. 
 Much malaria was doubtless imported from the Southern States and the West 
 
 Table 16. 
 
 Year. 
 
 No. of 
 specimens. 
 
 No. of 
 positive 
 specimens. 
 
 Year. 
 
 No. of 
 specimens. 
 
 No. of 
 positive 
 specimens. 
 
 1903 . 
 
 272 
 
 4 
 
 1912 . 
 
 513 
 
 52 
 
 1904 . 
 
 308 
 
 2 
 
 1913 . 
 
 746 
 
 5 
 
 1905 . 
 
 406 
 
 2 
 
 1914 . 
 
 437 
 
 4 
 
 1906 . 
 
 587 
 
 11 
 
 1915 . 
 
 417 
 
 4 
 
 1907 . 
 
 526 
 
 17 
 
 1916 . 
 
 476 
 
 3 
 
 1908 . 
 
 491 
 
 6 
 
 1917 . 
 
 247 
 
 1 
 
 1909 . 
 
 371 
 
 1 
 
 1918 . 
 
 79 
 
 1 
 
 1910 . 
 
 497 
 
 1 
 
 1919 . 
 
 60 
 
 1 
 
 1911 . 
 
 507 
 
 17 
 
 1920 . 
 
 48 
 
 1 
 
 Indies and South America and from rural districts of tidewater Maryland and 
 Virginia, particularly by summer visitors from the city. 
 
 The reports of the quarantine officers show that malaria in fatal form not 
 infrequently attacked those ill with small-pox or typhus fever sent from the 
 city to the old Marine Hospital, particularly in the fifth and sixth decades of 
 the nineteenth century. At this period many cases of severe malaria were taken 
 from vessels from southern ports, including Central America. Malaria was so 
 prevalent at the quarantine station that for many years, and until at least 1890, 
 the officers and employees were regularly dosed with quinine in whisky. 
 
 The decrease in the number of deaths from malarial diseases since 1900 
 has been associated with a decrease in the number of recognized cases in dis¬ 
 pensary and hospital practice and in the experience of leading clinicians. The 
 figures of examinations of blood for diagnosis in the bacteriological laboratory 
 since 1903 are shown in table 16. From table 16 it is evident that until 1918 
 malaria was frequently suspected by physicians. The percentage of cases in 
 which the tentative diagnosis was confirmed was relatively small. It was 2.5 
 per cent between 1903 and 1912, and 0.8 per cent between 1913 and 1920. 
 In the first period there were two well-marked minor epidemics, each covering 
 a period of two years. 
 
202 PUBLIC HEALTH ADMINISTRATION", ETC., IN BALTIMORE 
 
 Deaths from malarial fevers have been classified in the annual reports under 
 six headings: (1) intermittent fever, (2) remittent fever, (3) bilious fever, 
 (4) congestive fever, (5) malarial fever, and (6) typho-malarial fever. This 
 classification has been influenced by variations in fashion in both medical and 
 statistical nosology. The absolute figures and the rates (except for typho- 
 malarial fever, omitted for reasons given later) are set forth in table 17. From 
 a study of these, in connection with graph 2, an approximate idea of the course 
 of malarial fevers in Baltimore is attained. It is evident that intermittent 
 fever is the only variety that can be followed continuously throughout the series 
 of years. With the exception of 1816, from 1815 until 1909, it appears each 
 year as a cause of death. This form of malaria, on account of the characteristic 
 paroxysms of chill, fever, and sweating, occurring usually at regular intervals 
 measured in days, with its afebrile intermissions, was relatively easy of 
 diagnosis, and, of the group of malarial diseases, the one least likely to be con¬ 
 fused with other febrile affections, malarial and non-malarial, and for these 
 reasons the figures and rates for this disease may be regarded as a fairly close 
 approximation to the truth. 
 
 Attention is directed to the fact that intermittent fever has been a factor of 
 considerable weight in the death-rate, in one year (1821) having a rate of 30 
 and in 2 years (1871 and 1872) surpassing this figure, while in a number of 
 years (1821, 1822, 1829, 1834, 1837, 1842, 1864, 1867, 1868, 1869, 1870, 
 1871, 1872, 1873, and 1874) its rate was over 10. 
 
 The peaks in the curve for intermittent fever follow rather closely, but not 
 exactly, those of the curves for bilious fever and for the total of the malarial 
 diseases. With the exception of 1820, when there were 24 deaths recorded under 
 this heading (with a rate of 41), remittent fever has not been credited with any 
 large contributions to the malarial deaths in Baltimore. 
 
 To bilious fever, the old synonym for continuous or remittent fevers, in 
 contrast to intermittent malarial fevers, the great bulk of the deaths ascribed 
 to malaria were assigned from the beginning of our records until 1875. In the 
 latter year (the date, by the way, of the first use in Baltimore of death certifi¬ 
 cates signed by physicians) it practically dropped out of the local statistical 
 nosology, the deaths which previously would have been so ascribed being from 
 this date classed under malaria and remittent fever. A few deaths, however, 
 were thus classified as late as 1885. The number of deaths attributed to bilious 
 fever in the earlier years, say between 1812 and 1819, inclusive, is greater than 
 that attributed to any other single cause affecting all ages, with the exception 
 of consumption. During these 8 years, the deaths from the former averaged 
 about 12 per cent, and those from the latter about 17 per cent of the total 
 deaths from all causes. It is certain that before 1851, and probably after that 
 date, deaths from various causes other than severe continued malarial fever 
 were classed under bilious fever. In the first place, owing to the belief so 
 firmly held in the early part of the nineteenth century by certain Baltimore 
 physicians that yellow fever was an accentuated form of continued malarial 
 fever, it is extremely probable that not only in years of clearly recognized 
 epidemics of yellow fever, but in other years, at least until 1875 some cases of 
 true yellow fever, perhaps in atypical form, were called bilious fever. It is 
 probable, indeed, that in severe cases, and particularly when fatal, the diagnosis 
 between yellow and bilious remittent malarial fever was difficult, or even 
 
FEBRILE DISEASES 
 
 203 
 
 impossible. In the second place, as recorded by Davidge, dysentery, which so 
 often occurred in the same individual concurrently with malaria and was by 
 many believed to be a part of the malarial process, may have swollen the bilious- 
 fever death-list. In the third place, it is likely that until 1850 and for years 
 after, bilious fever shared with remittent fever, diarrhoea, and inflammation 
 of the bowels as classification categories for typhoid fever. In the fourth place, 
 it is not unlikely that during the early period some of the deaths from other 
 severe affections characterized by high fever of a remittent type, such as acute 
 endocarditis, pyemia, septicemia, and even typhus fever, were assigned to 
 bilious fever. On the other hand, the leading physicians, Drs. Allenby, Coulter, 
 and W. H. and W. A. Clendenin, in practice at Fell's Point, the chief home 
 within the city of bilious fever, were men of ability and discernment. 
 
 Deaths classed under congestive fever are considered to have been due to 
 that acute form of virulent malaria characterized by severe chill, very high 
 fever, delirium, coma, a prostration comparable to that of surgical shock, and 
 by massive infection (often particularly marked in the cerebral capillaries) 
 by malarial organisms of the aestivo-autumnal type. Synonymous with the 
 dreaded “ congestive chills ” and the pernicious malarial fever of the Southern 
 States and the tropics, appearing in the local statistical nosology first in 1836, it 
 was credited with death in every year (with the exception of 1848, 1855 to 1860, 
 1862, and 1876) until 1884. Its most conspicuous part was played between 
 1870 and 1874 (with death-rates above 10 in 1871-1873) towards the end of 
 the great wave of malaria beginning in 1862 and ending abruptly in 1875. 
 
 The term malaria first appeared in the local statistical nosology in 1877, and 
 disappeared in 1902 to reappear from 1910 to 1920. As is clear from table 17, 
 it was used indiscriminately for the other nosology categories applying to 
 malarial affections. Its curve follows closely that of deaths for all forms of 
 malaria. 
 
 Typho-malarial fever made its first appearance among the causes of death 
 in the Baltimore health reports in 1876, with 32 deaths. With the exception 
 of the following 2 years, it was credited with deaths until 1898. During this 
 period, the number of deaths assigned to this cause varied from 12 in the 
 latter year to 75 in 1885. It is impossible to determine what proportion of the 
 deaths recorded under this category was due to typhoid fever alone, to malaria 
 alone, to a combination of these two diseases, to malaria and other diseases, or 
 to other diseases without malaria. That typhoid fever and malaria may exist 
 in the same individual has long been clearly established, and is quite likely 
 that, when in combination, an attack of typhoid fever, from which recovery 
 would otherwise have occurred, might be determined to a fatal issue-by the 
 complicating malaria. Further, it is probable that in Baltimore typhoid fever 
 not infrequently attacked individuals who were the subjects of chronic or latent 
 malaria, and that, in this case, just as is known to happen in the course of 
 pneumonia., fractures, and other pathological conditions, the dormant malarial 
 infection may show an exacerbation. With all these considerations in view, it 
 has seemed, on the whole, wiser to omit the deaths ascribed to typho-malaria 
 from consideration here and to include them with typhoid fever. 
 
 When the curve for malaria as a whole is reviewed (graph 2), two points 
 stand out conspicuous^, its shape and height. The curve of the annual rates 
 for total deaths is divided into four large waves, the first and highest beginning 
 14 
 
204 
 
 PUBLIC HEALTH ADMINISTKATION, ETC., IN BALTIMOBE 
 
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206 
 
 IN BALTIMORE 
 
 PUBLIC HEALTH ADMINISTRATION, ETC., 
 
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FEBRILE DISEASES 
 
 207 
 
 before 1812, reaching its peak in 1822 with the extraordinary rate of 589 and 
 its low point in 1838 with a rate of 41; the second and much lower wave cul¬ 
 minating in 1862 with its highest peak, a rate of 69, in 1842; the third, showing 
 at its peak in 1871 a rate of 72 and ending in 1877 with a rate of 9, the lowest 
 in the city’s history; and the fourth, beginning in 1878, rising gradually to a 
 rate of 28 in 1881 and falling by gradual stages to a negligible value in 1915. 
 
 The first two waves possess striking characteristics which are lacking in the 
 last two, namely, multiple subsidiary peaks and depressions of great height and 
 depth, and, during the years covered by them—1812 to 1862—bilious fever is 
 the great contributory element, the curve for this cause being almost as high 
 as that for the total for malarial diseases, with which it closely conforms. In 
 
 Graph 2 (fiom table 17). Annual crude mortality rates from insect-borne 
 
 diseases, 1812 to 1920, inclusive. 
 
 the first great wave the peaks of the subsidiary waves are separated by intervals 
 of from 1 to 4 years. Between the extraordinarily high peak of 1822 and the 
 next one in 1826 there is an interval of 4 years, the rate for 1824, the mid-year, 
 falling from 589 to 101. The time intervals between the subsidiary peaks and 
 depressions of the second great wave are about the same as those of the first, 
 but the peaks are without exception all lower than the depressions of the 
 first great wave. In both the first and second waves a straight line would 
 almost connect the points marking the rates for the years of depression, and 
 the slant of the line in each instance would be acute, much more so, however, 
 for the low points of the first than of the second wave. With the ending of the 
 second wave, malaria, as a cause of death in Baltimore, had come to play a 
 comparatively subsidiary role. Thus, these two waves are characterized by 
 multiple epidemics of fatal malarial fever, in which the remittent type—now 
 
208 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 called sestivo-autumnal—commonly classified as bilious, but sometimes as remit¬ 
 tent (1819-1821, 1824, 1844, 1845, 1848-1850) and sometimes as congestive 
 (1836-1847, 1850-1854), played overwhelmingly the principal role. When the 
 rates for all forms of malaria are averaged for 5-year periods (table 18, graph 3) 
 the course of the disease may be followed wdth greater ease. From a level of 
 211 for the period ending in 1815, the rate fell to 141 in 1816-1820 and rose 
 to 264 in 1821-1825. From the highest point the rate fell continuously but by 
 somewhat uneven gradations to 23 in 1856-1860. Eemaining stationary during 
 the Civil War period, the rate rose during the next decade to 52 in 1871-1875. 
 
 Table 18. —Average rate of death by 5- and 10-year periods from insect-borne diseases , 
 
 from 1812 to 1920, inclusive. 
 
 Period. 
 
 Malarial fever. 
 
 Yellow 
 
 fever. 
 
 Malarial and 
 yellow fever. 
 
 Typhus fever. 
 
 Total. 
 
 By 5-year 
 periods. 
 
 By 10-year 
 periods. 
 
 By 5-year 
 periods. 
 
 By 10-year 
 periods. 
 
 By 5-year 
 periods. 
 
 By 10-year 
 
 periods. 
 
 By 5-year 
 
 periods. 
 
 By 10-year 
 
 periods. 
 
 By 5-year 
 
 periods. 
 
 By 10-year 
 
 periods. 
 
 I 
 
 1812-15... 
 
 211 
 
 • • • • 
 
 • • • • 
 
 
 211 
 
 • • • • 
 
 77 
 
 • • • • 
 
 288 
 
 • • • • 
 
 1816-20... 
 
 141 
 
 172 
 
 126 
 
 70 
 
 267 
 
 242 
 
 109 
 
 95 
 
 376 
 
 337 
 
 1821-25... 
 
 264 
 
 • • • • 
 
 1 
 
 • • • • 
 
 265 
 
 • • • • 
 
 116 
 
 • • • • 
 
 381 
 
 
 1826-30... 
 
 104 
 
 184 
 
 
 1 
 
 104 
 
 185 
 
 41 
 
 78 
 
 145 
 
 263 
 
 1831-35... 
 
 95 
 
 • • • • 
 
 
 • • • • 
 
 95 
 
 • • • • 
 
 37 
 
 • • • • 
 
 132 
 
 • • • • 
 
 1836-40... 
 
 52 
 
 74 
 
 
 • • • • 
 
 52 
 
 74 
 
 22 
 
 29 
 
 74 
 
 103 
 
 1841-45... 
 
 47 
 
 • • • • 
 
 
 • • • • 
 
 47 
 
 • • • • 
 
 12 
 
 • • • • 
 
 59 
 
 • • • • 
 
 1846-50... 
 
 42 
 
 44 
 
 
 • • • • 
 
 42 
 
 44 
 
 64 
 
 38 
 
 106 
 
 83 
 
 1851-55... 
 
 40 
 
 • * • • 
 
 6 
 
 • • • • 
 
 46 
 
 • • • • 
 
 10 
 
 • • • • 
 
 55 
 
 • • • • 
 
 1856-60... 
 
 23 
 
 32 
 
 
 3 
 
 23 
 
 35 
 
 2 
 
 6 
 
 26 
 
 41 
 
 1861-65... 
 
 23 
 
 • • • • 
 
 
 • • • • 
 
 23 
 
 • • • • 
 
 1 
 
 0 0 0 0 
 
 24 
 
 • • • • 
 
 1866-70... 
 
 34 
 
 29 
 
 2 
 
 1 
 
 36 
 
 30 
 
 5 
 
 3 
 
 41 
 
 32 
 
 1871-75... 
 
 52 
 
 • • • • 
 
 
 • • • • 
 
 52 
 
 • • • • 
 
 4 
 
 0 0 0 0 
 
 56 
 
 • • • • 
 
 1876-80... 
 
 15 
 
 34 
 
 3 
 
 1 
 
 18 
 
 35 
 
 2 
 
 3 
 
 20 
 
 38 
 
 1881-85... 
 
 26 
 
 • • • • 
 
 
 • • • • 
 
 26 
 
 • • • • 
 
 • • • • 
 
 • • • • 
 
 26 
 
 • • • • 
 
 1886-90... 
 
 19 
 
 22 
 
 
 • • • • 
 
 19 
 
 22 
 
 
 • • • • 
 
 19 
 
 22 
 
 1891-95... 
 
 11 
 
 • • • • 
 
 
 • • • • 
 
 11 
 
 • • • • 
 
 
 • • • • 
 
 11 
 
 • • • • 
 
 1896-1900. 
 
 9 
 
 10 
 
 
 0 0 0 0 
 
 9 
 
 10 
 
 
 • • • • 
 
 9 
 
 10 
 
 1901-05... 
 
 4 
 
 • • • • 
 
 
 0 0 0 0 
 
 4 
 
 • • • • 
 
 
 • • • • 
 
 4 
 
 • • • • 
 
 1906-10... 
 
 2 
 
 3 
 
 
 0 0 0 0 
 
 2 
 
 3 
 
 
 • • • • 
 
 2 
 
 3 
 
 1911-15... 
 
 1 
 
 • • • • 
 
 
 0 0 0 0 
 
 1 
 
 • • • • 
 
 
 • • • • 
 
 1 
 
 • • • • 
 
 1916-20... 
 
 • • • • 
 
 1 
 
 
 0 0 0 0 
 
 0 0 0 0 
 
 1 
 
 0 0 0 0 
 
 • • • • 
 
 • • • • 
 
 1 
 
 The drop in the rate to 15 in 1876-1880 was succeeded by a rise to 26 in 
 1881-1885. From this date the rate declined uninterruptedly to the vanishing- 
 point in 1916-1920. When the rates are averaged for 10-year periods (graph 4) 
 the course of the curve is even smoother. 
 
 Assuming that the absolute figures for deaths from malaria during these 
 periods are approximately accurate, from the information at hand, how may 
 these high rates and their fluctuations during these two periods be explained ? 
 
 The first wave of malaria, evidently well on its ascent before the present 
 story opens, comes under observation after a period of rapid growth due to 
 immigration on a huge scale of people from more northern climates and less 
 inured to malarial infection to a crowded little city situated on a stagnant 
 basin, bisected by streams sluggish in the summer, and surrounded by marshes, 
 
FEBRILE DISEASES 
 
 209 
 
 Graph 3 (from table 18). Crude mortality rates from insect-borne diseases, 
 averaged by 5-year periods, from 1812 to 1920. 
 
 Graph 4 (from table 18). Crude mortality rates from insect-borne diseases, 
 averaged by 10-year periods, 1812 to 1920. 
 
210 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 about which its chief industrial life was centered. For over 20 years previous 
 this community had carried on a thriving commerce with tropical or semi- 
 tropical ports, and this trade was still active and remained so for many years. 
 Thus, malaria in its severest forms must have been constantly imported to be 
 readily spread among a population but poorly acclimated. The lower parts, 
 at least, of the city abounded in stagnant pools and ill-drained streets, yards, 
 and vacant lots. Two reservoirs at the upper borders of the city furnished 
 additional breeding-places for mosquitoes. Cinchona bark, on account of the 
 wars, was probably too scarce and too high in price to be available for a large 
 proportion of the inhabitants. 
 
 The minor epidemic peaks of the second wave were perhaps associated with 
 the ultimate killing off and reaccumulation of susceptibles (immigration being 
 largely responsible for the latter) and the neglect after a year or so of sanitary 
 measures inaugurated during the epidemic peaks. 
 
 The third great wave, extending over the 15 years between 1862 and 1877, 
 differs radically from its two predecessors. Its ascent is at first gradual and 
 broken by a minor wave without a decided peak covering the last 3 years of the 
 Civil War and then abrupt, reaching its highest level in 1871. From this point 
 there is a gradual drop during the 3-year period, 1872 to 1874. In 1875 there 
 is a marked drop to 14, and the wave culminates in 1877 with the lowest rate 
 hitherto attained. The intermittent type of malarial fever now makes a much 
 more decided contribution to’the total rate than before, and its curve follows 
 very closely that of the total curve. The curves of bilious fever and of con¬ 
 gestive fever, the two elements representing continued or sestivo-autumnal " 
 malarial fever, conform very closely with the curves of the total malarial rate 
 and with the rate for intermittent fever. Indeed, were the rates for these two 
 types combined, the resulting curve would closely fit both as to area and form the 
 curve for intermittent. 
 
 The decline in the rate for continued fever and the consequent comparatively 
 low total rate during and immediately after the Civil War are probably directly 
 associated with the cutting off of communications of Baltimore from the 
 Southern States, the West Indies, and Central and South America during this 
 period, and the subsequent rise in the death-rate from this type of malaria in 
 the succeeding years up to 1871 and 1872, may well be intimately associated 
 with the assumption of relations by land and by sea with these sources of more 
 virulent malaria. It will be noted that during the Civil War there was a 
 distinct, though not very great rise in the curve for intermittent fever, with a 
 subsidence before the beginning of its great rise to rates of over 30 during 1871 
 and 1872. It is evident that the restrictions upon civilian intercourse during 
 the Civil War more than counterbalanced any infection of the city by troops. 
 The rise in the rates for malarial fevers between 1866 and 1874 was perhaps 
 influenced to a considerable degree by the large immigration of unacclimatized 
 people from Ireland and Germany. Among conditions of a local character 
 favoring the fall of malarial deaths were the improvements resulting from the 
 draining and filling at Fell’s Point and along lower Jones Falls and Harford 
 Run, the abandonment of the Franklin Street and Belvedere Reservoirs, and 
 the covering over of Chatsworth’s and Schroeder’s Runs. 
 
 The last great wave, beginning in 1878, is characterized by a curve that rises 
 almost abruptly to its highest point with a rate of 28 in 1881 and falls very 
 
FEBRILE DISEASES 
 
 211 
 
 gradually with a few minor rises (1893-1896 and 1897-1900), disappearing 
 almost entirely in 1915. This curve is, therefore, relatively smooth. The rate 
 for the newly introduced rubric malaria is the chief contributor to the total 
 rate, and, as previously explained, this term must include deaths from both 
 the intermittent and the continuous types of malarial fever. It will be noted 
 that with the decline of its curve from 1897 and its disappearance from the 
 nosology in 1902 the curve for intermittent fever rises. After 1910, no dis¬ 
 tinction was made between continued and intermittent fevers. Bilious fever 
 contributes a small quota to the total rate until 1885, and remittent fever is 
 responsible for a considerable contribution thereto until 1897. To what factors 
 is the course of the malarial curve from 1877 to be attributed? The reasons 
 for the rise immediately after this date are as uncertain as are those for its fall 
 immediately before. The rise and the peak of the curve coincide with the 
 beginning and continuation of a migration from southern Europe, i. e., Bohemia 
 and Italy, and from northern Europe, particularly of Polish Jews, the people 
 from both sections, however, probably subject to malaria in their home countries. 
 At this period, too, virulent malaria was frequently introduced at Sparrows 
 Point by ore steamers from Cuba. The city was extending not only to the north, 
 but to the northeast and northwest to higher ground. People also settled in 
 the northeast along the uncovered portion of Harford Run and at the extreme 
 south at Locust Point about docks. Facilities for reaching the lower tide¬ 
 water counties of Maryland and Virginia for vacations and excursions were 
 greatly increased on account of the development of steamboat lines. On the 
 other hand, the clipper ship had well nigh disappeared, and the southern and 
 tropical shipping trade was greatly curtailed. Thanks to the improvement in 
 paving, grading, and filling, the development of more and better storm-water 
 sewers, the improvement or abandonment of cow stables, the improvement in 
 garbage collection and nuisance control, considerable changes for the better 
 took place in those general conditions which favor the breeding, protection, and 
 distribution of mosquitoes. Overflowing cesspools, somewhat better controlled 
 than formerly, were not gotten rid of until after malaria ceased to be a cause 
 of death in Baltimore. The recent anti-mosquito campaign of the health de¬ 
 partment came after this date. 
 
 Though the physicians of Baltimore in general, and the leading physicians 
 in particular, were well grounded in the various aspects of malaria, and Coun¬ 
 cilman and Abbott (52) had confirmed Lavaran’s studies on the malaria para¬ 
 site at Bayview Hospital as early as 1885 and had taught the resident physi¬ 
 cians of that institution the methods of blood examination as related to the 
 diagnosis and treatment of this disease, it was not until the opening of the 
 medical dispensary and wards of the Johns Hopkins Hospital under Osier, in 
 1889, that critical routine studies of the different forms of the malarial para¬ 
 sites in relation to the various types of malarial fever were regularly practiced 
 in this city, and a certain looseness in diagnosis, not only between the various 
 forms of this disease, but between them and wound infections, typhoid fever, 
 and other diseases, on the part of the general practitioner began to be rectified. 
 By 1895, the activities of the pupils of Councilman, Abbott, Welch, and Osier, 
 the influence of these teachers, the entry upon the held of consultation practice 
 of Osier, Mitchell, Lockwood, C. B. Gamble jr., Thayer, Simon, and others so 
 reacted upon the other hospitals and upon general medical practice that the 
 
212 PUBLIC HEALTH ADMINISTRATION", ETC., IN BALTIMORE 
 
 diagnosis of malaria became more rigid and its treatment more exact. An 
 important role in correcting the confusion between malaria and typhoid fever 
 and tuberculosis was played after 1900 by the bacteriological laboratory and by 
 the critical attitude of Dr. Jones towards death certificates. 
 
 The decrease in malaria and its final disappearance as a serious menace as 
 a cause of death in Baltimore are probably due (1) to breakdown in the trade 
 communications with localities in which malaria in severe types is endemic; 
 (2) to the very gradual improvement in drainage, due to filling, grading, the 
 building of storm-water sewers, and the covering of the three streams and the 
 straightening and narrowing of the bed of the fourth, Jones Falls; (3) to the 
 gradually increasing use of cinchona bark and its preparations, both in treat¬ 
 ment and in prevention. It has been shown that malaria had almost entirely 
 disappeared before the institution of the organized anti-mosquito campaign 
 in 1910. 
 
 Of the above measures, undoubtedly the most important was the freer use of 
 quinine during the last 50 years, not only in the treatment of recognized mala¬ 
 ria and as a preventative, but as a tonic, either alone or with other drugs in the 
 treatment of all sorts of ailments. In the course of time, a large proportion 
 of the population was saturated with quinine. During much of the time when 
 malaria was at its worst, cinchona bark and its derivatives were scarce and so 
 high priced as to be out of the reach of a large part of the population. Changes 
 in the plan of treatment of severe malaria, according to which cinchona bark 
 and its preparations were given earlier and in larger doses, and particularly by 
 the hypodermic method, without waiting for results from the bleedings, emetics, 
 purgings, and blisterings, as was formerly the custom, must have materially 
 lowered the mortality. 
 
 YELLOW FEVER. 
 
 In Chapter Y, in tracing the important part yellow fever played in determin¬ 
 ing the policies of public-health administration in Baltimore, and particularly 
 in regard to quarantine measures, some account has been given of the distribu¬ 
 tion of the disease in Baltimore and of the views held in regard to its origin 
 and mode of spread, and this need not be repeated in detail here. 
 
 Certain cardinal facts stand out clearly, namely, that (1) yellow fever in 
 epidemic form in Baltimore nearly always began at Fell’s Point, the docking- 
 place of ocean-going vessels; (2) it always remained limited to that area, 
 except under the influence of unusually strong winds blowing over the district 
 primarily infected towards the section secondarily affected; (3) when cases of 
 yellow fever were removed from the primarily infected district to high ground 
 (in the country or at the hospital at Broadway and Monument Streets), 
 secondary cases did not occur; and (4) when residents of West Baltimore, who 
 had contracted the disease while working in or visiting the infected area at 
 Fell’s Point, remained in their homes and when cases of yellow fever were 
 imported from Fell’s Point into West Baltimore (1797, 1855, 1883, and 1899), 
 there were no recognized secondary cases. 
 
 In the discussion of malaria it has been shown that conditions favorable to 
 mosquito-breeding, while particularly favorable at Fell’s Point, must have 
 existed throughout at least most of the city. That the Anopheles mosquito 
 bred very widely in Baltimore is clear from the known distribution of cases of 
 
FEBRILE DISEASES 
 
 213 
 
 malaria. From the evidence at hand it would seem clearly established that the 
 Stegomyia mosquito was at least in most years limited to FelFs Point and the 
 Lazaretto Point and their immediate environs. Perhaps this species of mos¬ 
 quito rarely, if ever, survived the Baltimore winter, and, having to be imported 
 each year and arriving late in the season, it did not have opportunity for wide 
 spreading from the region of the docks (Lazaretto and FelFs Point) at which 
 it landed. 
 
 The recorded data as to reported cases and deaths of recognized yellow fever 
 at the quarantine stations have been presented in the chapter relating to quar¬ 
 antine. The mortality within the city is presented in table 17 and graph 2. 
 
 It is very improbable that, with the large shipping trade between Baltimore 
 and the West Indies and Charleston and Savannah, not to mention other places 
 where yellow fever was indigenous or often epidemic, the disease appeared 
 here for the first time in 1794. While this year certainly marks the first great 
 epidemic of this disease recognized as such in Baltimore, it is extremely probable 
 that not infrequently before this date from a few to a considerable number of 
 cases must have occurred and have been mistaken for bilious remittent malarial 
 fever in both mild and severe forms. Indeed, Davidge, one of the first in North 
 America to recognize that yellow fever is not contagious, held that it was only 
 a heightened form of malarial fever, a view shared by many of his colleagues; 
 and, as a matter of fact, in those of the early epidemics which are recorded in 
 fullest detail, the first cases were invariably believed to be bilious remittent 
 fever, and it was only after much investigation, discussion, and consideration 
 that the existence of yellow fever was established and officially acknowledged. 
 In a community in which some of the leading physicians were honestly con¬ 
 vinced of the fundamental identity of two affections with such a large propor¬ 
 tion of their cardinal symptoms in common, it was not to be expected that the 
 authorities would lightly declare that cases of the annual summer visitation of 
 continued fever belonged to the category yellow , and thus advertise the pres¬ 
 ence of a malady to a prejudiced world, which, in its ignorance, classed it as a 
 contagious pestilence, thereby, simply because of the use of a mere name or 
 label, which in reality signified an error, bringing all the disadvantages and 
 losses entailed by a quarantine upon a seaport whose prosperity depended upon 
 a free and untrammeled commerce. This being the attitude towards yellow 
 fever and its recognition as a separate disease after two considerable epidemics 
 within 4 years (1794-1797), it is extremely unlikely that, in the loosely organ¬ 
 ized administration of Baltimore Town before the scare of 1793, any great 
 pains were exercised by either physicians or authorities to discriminate be¬ 
 tween yellow and bilious fever at FelFs Point, where illness and death of con¬ 
 tinued fever were common each year. 
 
 The doctrine of the local origin of yellow fever and the failure to recognize 
 that it was commonly imported on ships were not peculiar to Baltimore in the 
 latter part of the eighteenth and the early years of the nineteenth centuries; 
 the same errors were made in Philadelphia and in Charleston, South Caro¬ 
 lina. Notwithstanding these opinions, the Baltimore city council quarantined 
 against Philadelphia in 1797 and again in 1800, when yellow fever broke out 
 there before its presence was recognized in Baltimore. 
 
 Owing to lack of data in regard to the number of deaths annually ascribed 
 to malarial fevers prior to 1812, comparative studies of the death-rates of 
 
214 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 malarial and yellow fevers in Baltimore can not be made for any year prior 
 to 1819, the first subsequent year with recorded deaths from yellow fever. 
 
 The rather meager information in regard to 1794 is drawn from the accounts 
 of Quinan and Cordell, both of whom wrote many years later. The governor’s 
 quarantine officers and the local board of health were publicly criticized as 
 early as July 8 for permitting yellow fever to gain entrance, but it was not 
 until August 13 that Drs. Coulter, Brown, and Goodwin reported malignant 
 bilious fever at Fell’s Point, to which location the disease was apparently con¬ 
 fined. The board of health reported the city free of the disease on October 1 
 and admitted only 344 deaths from all causes in August and September. 
 Cordell gives the number of deaths due to yellow fever alone for this year as 
 360. There is no record of the total number of cases. If the actual fatalities 
 from yellow fever were 360, and if it is true that the disease was confined to 
 Fell’s Point, where the total number of inhabitants could not have far exceeded 
 2,500, the attack and the death-rates were appalling, and the death-rate of 
 2,400, calculated on the estimated population of the whole town, high as it is, 
 gives but a very incomplete idea of the severity of the scourge. 
 
 Concerning the yellow fever epidemic of 1797, there exist two accounts which 
 supplement each other, the report of the commissioners of health to the mayor 
 and city council (53), published in the New Yorlc Medical Repository for 
 November, 1797, and the essay of John B. Davidge (33), published the follow¬ 
 ing year. 
 
 The commissioners organized as a board of health on June 5 and soon after¬ 
 wards enforced the new quarantine act on shipping from the West Indies and 
 took precautions to examine travelers from Philadelphia, when later in the 
 season a “ malignant fever ” appeared there. 
 
 During July and August the health of the citizens of West Baltimore was 
 unusually good; many nuisances had been removed, some low places had been 
 filled, and the streets were cleaner than usual. In East Baltimore (Fell’s Point) 
 a “ bilious complaint ” regarded as the common sickness of the season com¬ 
 menced early and gradually progressed to a worse stage. On August 26, in 
 response to letters from the board, Drs. Coulter, Allender, and Joquit, of 
 Fell’s Point, while confessing to the presence of a severe type of continued fever, 
 replied to the effect that they did not regard it as departing from the usual 
 bilious remittent and intermittent, and cited their experiences as evidence that 
 the fatality was not high. According to Dr. Coulter, on the fourth or fifth day, 
 if timely remedies had not been applied, vomiting of black matter like coffee- 
 grounds and sometimes mixed with dark blood occurred, attended with profuse 
 hemorrhages from the nose, gums, and intestines, which generally carried the 
 victim off on the sixth day. Since June he had attended upwards of 300 such 
 cases and had lost only 8. At a meeting of the physicians of the city called on 
 August 28, after the reading of these letters in reply to the questions of the 
 president of the board of health, they all denied having knowledge of the exis¬ 
 tence of any contagious or yellow fever, except Dr. Davidge’s case of a lady 
 lately returned from Philadelphia (previously narrated elsewhere) and a sus¬ 
 picious case attended by Dr. Smith. The next day, Drs, Goodwin, Moores, and 
 Davidge, who investigated the cases of fever at Fell’s Point, reported that 
 they “ discovered nothing like a malignant, contagious, or yellow fever; the 
 
FEBRILE DISEASES 
 
 215 
 
 patients whom we saw all labored under the common bilious remittent, and 
 will generally recover, with common attention.” 
 
 On September 3, five members of the board, with Dr. Moores as medical 
 adviser, investigated conditions at Fell’s Point, and though they found that 
 there had occurred a considerable extension of the disease, especially among 
 the poor, they were not convinced, officially at least, that the malady was yellow 
 fever. The next week, some days after the gathering of a crowd of people from 
 all parts of the city to witness the launching of a frigate at Fell’s Point, there 
 was a considerable extension of the disease in that district and the appearance 
 of several cases in West Baltimore. On September 8, the first case of yellow 
 fever was officially reported by Dr. Moores. According to Davidge, the most 
 prominent advocate of the identity of bilious remittent and yellow fever, “ a 
 little later, the disease raised from the grade of bilious to yellow fever and 
 mounted its chariot of death and drove furiously through the streets .... and, 
 conveyed by the northeast wind, it scattered itself all along Federal Hill and the 
 west end of the basin; whichever direction the miasmata (arising from the 
 stagnant water along the marshes and wharves), controlled by the winds, took, 
 the disease tread closely upon its footsteps.” It sped to the end of Hanover 
 Street and its vicinity and in a short time it penetrated “ to the vitals of the 
 city and affected many who were not near the point or the wharves.” Potter 
 gives the date of the great wind as September 17 and its direction as from the 
 southeast, blowing the “ pestilential effluvia northwesterly and spreading the 
 fever along Frederick, Gay, South, and Calvert Streets. Since it was found 
 unpracticable to transport the sick to the quarantine hospital at Hawkins’ 
 Point, a private house near Fell’s Point was converted into a hospital, capable 
 of accommodating but a small proportion of the sick poor. At a meeting of the 
 board of health with the physicians on September 11, the latter advised against 
 the removal of the inhabitants of Fell’s Point to the country and the cutting off 
 of communication between Fell’s Point and the rest of the city. 
 
 In the report of the board of health, the actual number of cases and deaths 
 of yellow fever is not given, but from the following figures for the total deaths 
 for almost equal periods before and during the epidemic some estimate of its 
 ravages may be obtained: Deaths from all causes, August 1 to September 11 
 (42 days), adults 97, children 74, total 171; September 11 to October 29 (48 
 days), adults 408, children 137, total 545. According to Davidge, the greatest 
 number of deaths in the west end, or city proper, in any one day was 8, while 
 the list of deaths at the point was for some time considerable. The epidemic 
 began to subside about October 1 and was nearly or quite extinct by Novem¬ 
 ber 1. Of the inhabitants of Fell’s Point, 2,679 remained throughout the epi¬ 
 demic and 671 removed. 
 
 From the meager accounts extant, it seems probable that yellow fever existed 
 at Fell’s Point in 1798 and certainly was present in 1799, but definite records 
 of the number of cases and deaths are lacking. 
 
 According to the report of the Medical Faculty to the mayor on the origin of 
 the pestilence in 1800, the disease was of domestic origin and not related to 
 shipping, having started at Fell’s Point in May, and its principal source was 
 the cove extending from the mouth of Jones Falls to the interior of Fell’s Point. 
 Potter records that the increment of cases could be calculated with tolerable 
 
216 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 accuracy by observing the variations of the winds. Though no record is avail¬ 
 able of the actual number of cases and deaths, the epidemic was of considerable 
 extent, for on August 28, the day the disease was acknowledged to be yellow 
 fever, the board of health arranged to have the cases reported to it daily by 
 special messengers. On September 2 a special encampment was established for 
 the poor who wished to flee from the disease, and on the 5th, cases were reported 
 in West Baltimore. The epidemic ceased October 22. The total deaths for the 
 year were given as 1,197, or a rate for all causes of 45. 
 
 Cases of yellow fever were recognized at FelPs Point in 1802, but according 
 to the scanty accounts not in epidemic form. 
 
 The sole authority found for the existence of yellow fever in 1807 is Potter, 
 who records it as of special interest, to prove the local origin of the disease, 
 since it occurred during the period of the embargo, when not a foreign ship 
 entered the port. He quoted Drs. Allender and Clendenin, who had experienced 
 the former epidemic at FelPs Point as attesting to the true character of the fever. 
 
 Concerning the epidemic of 1819, the greatest since 1794, and the last one 
 of serious dimension, there is considerable literature. Reese’s pamphlet (25) is 
 especially clear and full. The first two cases occurred on July 21 and 22 in two 
 men who frequented Smith’s Dock at the point. At this dock were two schoon¬ 
 ers, recently from the West Indies, laden with coffee and hides. After the out¬ 
 break of these two cases, the vessels were sent back to the quarantine grounds, 
 but as the health officer found the crew healthy and the cargoes in good condi¬ 
 tion, they were allowed to return to dock. Soon afterwards, 5 other cases of yel¬ 
 low fever occurred in men working on Smith’s Dock. The outbreak was attrib¬ 
 uted to the foul condition of Smith’s Dock and the Frederick and Gay Street 
 Docks, to the general insanitary condition of FelPs Point, and to two stagnant 
 ponds between the point and the lazaretto. The disease afterwards broke out at 
 the latter place. By August 14, cases were apprehended at the lower east end of 
 FelPs Point, at least a mile from Smith’s Dock. By August 28, about 50 cases 
 had been reported, and the deaths were said to be about one-fifth the number 
 attacked. Under the influence of a strong southeast wind, the disease was 
 rapidly spreading towards Jones Falls and the city to the west of it, when, 
 after veering, the wind blew for some days with equal force from the northwest, 
 and the disease ceased to spread in that direction. Many persons, certainly over 
 half of the population, fled from FelPs Point, some to the country and others 
 to the city proper. Many cases were sent to the new Maryland Hospital on 
 Broadway. There were 1,010 cases reported, but Reese estimated the total 
 number of cases at 1,200. The official report placed the deaths at 350. 
 
 Four deaths were credited to yellow fever in 1821, but the number of cases 
 was not recorded. In 1853 there was a sudden outbreak of 18 cases of what was 
 recorded as yellow fever, all fatal and occurring within a single block of 
 dwellings at FelPs Point. The origin of the disease was not traced. “ About 
 50 cases,” one-half of which are said to have proved fatal, are recorded in the 
 annual report of the board of health for 1854 as occurring at Fell’s Point, in 
 the same locality as in the previous year. The disease was regarded as of local 
 origin. The deaths (13), from yellow fever occurring within the city during 
 1855 were all among refugees admitted from Norfolk, Gosport, or Portsmouth, 
 at the entrance of the Bay. No secondary cases developed from these. 
 
FEBRILE DISEASES 
 
 217 
 
 Early in the summer of 1859, a vessel from the West Indies was allowed to 
 pass quarantine on account of her bill of health, and 5 laborers, who had been 
 engaged in unloading her, developed typical yellow fever. Though they were 
 nursed in their homes, the disease did not spread. A month after the departure 
 of the vessel a pernicious fever, attended in some cases with black vomit, 
 appeared on FelPs Point, and in several cases it proved fatal. In 1869 there 
 were 27 deaths from yellow fever at FelPs Point. The 71 cases with 59 deaths 
 (44 of the latter within the city and 15 at the quarantine hospital) in 1876 
 were recorded as typho-malarial fever by the commissioner of health. Dr. W. T. 
 Councilman, in a personal communication, is the authority for the statement 
 that Dr. E. Lloyd Howard, the quarantine physician, who attended many of 
 them, regarded the disease as certainly yellow fever. According to the report 
 of the commissioner of health, the cases occurred in rapid succession on Caroline 
 Street near Thames Street, opposite to the City Dock. The illness was very 
 acute, death often taking place within 24 hours. Of the 46 cases not removed 
 to the quarantine hospital, only 2 recovered. The disease did not spread beyond 
 this immediate locality. The few cases recorded in 1883 and 1899 developed 
 in sailors taken sick on ships at the docks after passing quarantine; no secon¬ 
 dary cases occurred. 
 
 In the 49 years between 1850 and 1899, cases of yellow fever were recognized 
 at the quarantine station on ships in 23 years and the disease appeared in the 
 city in at least 8 of these years. In only 2 of these 8 years, 1854 and 1883, w^as 
 the disease not recorded as present on ships inspected at quarantine. As a 
 matter of fact, during the earlier years of this period, as well as during the 30 
 years between 1821 and 1850, when no cases and no deaths of yellow fever 
 were recorded in the city, it is extremely probable that yellow fever often got 
 into the city and either was not recognized, or, if recognized, its presence was 
 not recorded by the officials. Considering the extensive commerce with yellow- 
 fever infected places and the looseness of the quarantine administration of a 
 city committed to the doctrine that yellow fever was of local origin, it would be 
 preposterous to conclude that yellow fever completely failed to gain access to 
 Baltimore between 1822 and 1853. 
 
 During this period, “ bilious remittent ” fever was expected to recur at FelPs 
 Point widely spread and in deadly form each summer and fall, and what was 
 more likely and consistent than that the cases of yellow fever occurring at the 
 same time should be reckoned as belonging to the former category. The remark¬ 
 ably high death-rates attributed to bilious fever during this period would seem 
 to demand this assumption for their explanation. 
 
 The failure of the disease to spread among the inhabitants of the city in 1855, 
 when there were 13 deaths among refugees from Norfolk, Portsmouth, and 
 Gosport, is not remarkable in the light of the occurrences of other years. It is 
 likely that these refugees belonged exclusively to the type of people who would 
 have received shelter on the west side of the city on high ground, rather than 
 at FelPs Point. 
 
 From the resume given of the history of malaria and yellow fever in Balti¬ 
 more, it is evident that in the late years of the eighteenth and in the earlier 
 years of the nineteenth centuries, these two mosquito-borne diseases were very 
 much confused. It is certain that in the epidemic of 1819 many of the earlier 
 deaths at least were attributed to bilious fever and that for this year the official 
 
218 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 figures for deaths from yellow fever were lower than actually experienced. It 
 is certain that, owing either to mistakes in diagnosis or to wilful intent to hide 
 the truth, in other years after 1819 a considerable number of deaths from yellow 
 fever were ascribed to bilious fever. Indeed, in 1853 and 1854, while descrip¬ 
 tions of outbreaks of yellow fever, with the number of deaths, are given in the 
 text of the annual reports, this disease did not appear in the official mortality 
 tables. For these two years it has been assumed that the deaths from yellow 
 fever were credited to bilious fever, and the figures in the tables have been 
 corrected accordingly. A similar correction has been made for 1876, when 44 
 deaths from what the quarantine physician who was well acquainted with the 
 disease called yellow fever were attributed to typho-malaria by the commissioner 
 of health. While the official figures for deaths credited to malaria and yellow 
 fever individually can not be accepted as accurate, the sum of the deaths for 
 the two must reflect with a fair degree of accuracy the total fatality from the 
 mosquito-borne diseases. 
 
 The averaged rates for 5-year and 10-year periods for total malaria and for 
 yellow fever taken together are given in table 18. From 1812 to 1825, these 
 affections were responsible for an average annual death-rate of nearly 250. By 
 1826-1830 the rate had fallen to 104 and by 1831-1835 to 95. High rates for 
 bilious fever ended in 1836 (table 17) and it is probable that the period of fre¬ 
 quent importation of severe tropical malaria and of yellow fever ended about 
 this time. It is significant that bilious fever is described as being most preva¬ 
 lent and fatal at Fell’s Point, the only place where yellow fever flourished. The 
 combined rate fell continuously until 1846-1850 to 42. During the next 5 
 years, synchronously with three recorded slight outbreaks of yellow fever, the 
 rate rose to 46. Falling to 23 in 1856-1860, and remaining stationary during 
 the next 5 years in connection with known but small outbreaks of yellow fever, 
 the rate rose between 1865 and 1875 to 52. The rise in the rate in 1881-1885, 
 after a fall to 18 in 1875-1880, was perhaps associated to some degree with 
 unrecognized yellow fever. It is doubtful if yellow fever was responsible for 
 any considerable number of deaths after 1876. With the annual rates averaged 
 for 10-year periods, except for a slight reaction for the decennium ending in 
 1880, the course of the curve from 1812 to 1920 is continuously downwards. 
 
 TYPHUS FEVER. 
 
 The local chroniclers record no serious epidemic of typhus fever during the 
 eighteenth century, and its early history in Baltimore is shrouded in mystery. 
 According to Jameson, it was present in 1799 and 1800. Typhus and typhus 
 mitior are mentioned in the reports of the censors of the Medical and Chirurgi- 
 cal Faculty as among the diseases prevalent in 1809, 1810, and 1811, but not as 
 serious epidemics. Typhus fever is so rarely alluded to before 1852 in the 
 annual reports of the health department that, but for its appearance in the list 
 of interments as a considerable cause of death, its existence as a public-health 
 problem would not be suspected. 
 
 The sudden outbreak of typhus fever in 1814, with 56 deaths, as compared 
 with none in 1812 and only 1 in 1813, may have been due to its spread from 
 local endemic foci of mild type to the American troops defending the city, to 
 
FEBRILE DISEASES 
 
 219 
 
 importation from other American cities—New York or Philadelphia for 
 instance—or, on the other hand, to contact on the part of civilians or troops 
 with the British forces operating in Maryland. On account of the effective 
 blockade of the whole Chesapeake Bay by the British fleet, the disease could 
 hardly have been imported directly from Europe to Baltimore by vessels of 
 commerce in this year. However this may be, as may be seen from table 17, 
 graph 2, there began in 1814 an epidemic of great intensity, which extended 
 over a period of 15 years, and no year was without fatalities from this cause 
 until 1860. 
 
 The course of the disease during the 15 years between 1813 and 1828, as 
 evidenced by the death-rates, was that of a great epidemic wave of a virulent 
 disease, in which the death-rate was for 13 consecutive years over 50 and which 
 was broken by three very high subsidiary waves. The first of these coincides 
 with the war with Great Britain, and the second and third with the period of 
 great financial depression and want that occurred in Baltimore and elsewhere 
 following the Napoleonic Wars, during which typhus fever was particularly 
 prevalent and virulent in Europe. It is likely that the beginning of this great 
 wave was connected with the introduction of the disease from contact with the 
 British expeditionary forces, and that its continuation after peace in 1815 was 
 due to constant reimportations upon the resumption of commerce and immigra¬ 
 tion with Europe, particularly with Ireland and the ports of Liverpool, Glas¬ 
 gow, London, and Bremen. During this period the contribution of typhus fever 
 to the general death-rate was a heavy one. 
 
 The next wave, beginning in 1829 and reaching its highest point in 1832 
 with a death-rate of 59, was associated with the crowds of immigrants, asserted 
 by the quarantine officer in 1831 to be composed largely of the lame, halt, blind, 
 and poverty-stricken, brought in by vessels in ballast from Europe, their passage 
 often paid by the parishes from which they came. 
 
 By 1840, typhus fever in Baltimore had become stabilized at a comparatively 
 low rate and remained so until the definite epidemic of 1847-1851, which was 
 clearly associated with the great immigration in those years from famine and 
 typhus stricken Ireland. In 1847, 101 cases of typhus, of whom 17 died, were 
 removed from ships at quarantine; and, as late as 1852, 48 cases were removed 
 from a single ship, and of 144 of her passengers held at the lazaretto for observa¬ 
 tion, 80 developed the disease. From the frequently quoted work of Buckler, 
 it would appear that in this epidemic the chief incidence of the disease was 
 among the recently landed immigrants and the free blacks. Among the former, 
 some were sent directly from ships to the almshouse, and many after they had 
 dwelt as servants in private families for one or two weeks after landing. In 
 May and June of 1849 there was an epidemic of typhus confined almost exclu¬ 
 sively to free negroes. “ In rows of houses occupied by Germans, Irish, and free 
 blacks, it would invariably single out the latter, in many instances seizing an 
 entire family.” Of 83 cases, all blacks with one exception, sent to the almshouse 
 infirmary, ranging in age from 5 to 75 years, 39 were fatal. 
 
 “ The cases were far more fatal in the beginning than at the close of the epidemic; 
 of the first 18 cases admitted, all died, and of the last 20, all recovered. The mystery 
 is why the blacks alone should have suffered. The cases came from Strawberry Alley 
 on the east, Run Alley on the west, Biddle Alley on the north, and intermediate points. 
 L Alley, near the center of the city and directly back of the public stores, was entirely 
 depopulated.” 
 
 15 
 
220 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 The greater incidence of the disease among the free than among the slave 
 negroes is probably explainable in two ways—the greater number of the former 
 in the population (over 8 times) and their greater exposure and comparative 
 undernourishment. The slaves were better housed on their masters* premises 
 and were well fed, while the free negroes, relatively underfed, lived largely in 
 alleys in closer contact with the poorer immigrant whites. The greater sus¬ 
 ceptibility to the disease of the negro than the poor white was probably due to 
 the fact that he was new to it and that many were heavily infested with lice. 
 
 Buckler pointed out that the quarantine system, as conducted, had never 
 kept out the disease and that the policy of the city government towards the 
 disease within the city was hopelessly ineffectual. 
 
 Between 1856, when the disease had again become stabilized at a low rate, 
 and 1869, cases were encountered at the quarantine station in only 3 years, 
 1857, 1858, and 1866. 
 
 There were flareups of the disease in 1866-1867, 1870-1871, and in 1875, 
 and the first two of these coincided with European wars. In 1870, 282 cases of 
 typhus were removed from ships at quarantine, and in each of the 3 succeeding 
 years cases were similarly detected. 
 
 Between 1875 and 1892, cases were apprehended at quarantine in only 3 
 years, 1878, 1887, and 1892. Only 2 deaths were recorded in the city between 
 1884 and 1918. The salient features of the course of typhus fever are well 
 brought out in the annual mortality rates averaged for 5- and 10-year periods 
 (table 18, graphs 3 and 4). From the curves three epidemic waves stand out 
 distinctly. Following the curve of the rates averaged for 5-year periods, the 
 first wave, beginning with a rate of 77 for 1812—1815, rose to a peak with a 
 rate of 116 in 1821-1825, and then declined continuously to the low level of 12 
 in 1841-1845. The second wave reached its sharp peak in 1846-1850 with a 
 rate of 64 and fell abruptly to its low ebb in 1861-1865. The third wave, with 
 its flattened peak, marked by rates of 5 in 1866-1870 and of 4 in 1871-1875, 
 had subsided by 1876-1880. From 1880 there was no significant number of 
 deaths. 
 
 Typhus fever may be said to have run its course in Baltimore, certainly 
 between 1813 and 1895, without any interference worthy of the name by the 
 health department, either by keeping the diseases from gaining entrance through 
 the port or by restrictive measures applied within the city. No serious efforts 
 were made even to secure the reporting of cases, and when cases came to the 
 knowledge of the health department, no adequate measures were taken to 
 prevent the spread of the disease. Hospitalization was attempted in the cases 
 of only some of those who were in such dire want and affliction that they could 
 not be taken care of in their dwellings, and these were placed in the public wards 
 of general hospitals without any precautions. The gradual disappearance of 
 the disease was due entirely to causes unconnected with local public-health 
 administration. 
 
 No distinction was made between typhus or typhus gravior and typhus mitior, 
 and typhoid fever did not enter into the local statistical nosology until 1851; 
 therefore the question as to the confusion of typhus and typhoid fevers in the 
 tables of causes of death naturally arises. This question will be considered in 
 detail under the discussion of the latter disease; suffice it here to state that 
 there must have been some confusion on this point, certainly in the earlier 
 
FEBRILE DISEASES 
 
 221 
 
 years, that the rates for typhus fever as given are on this account too high, 
 but that, on the whole, it is probable that the errors connected with typhoid 
 fever affected the rates for continued malarial fever to a much greater degree 
 than those for typhus fever. If typhoid fever was very prevalent and deaths 
 from it were classified under typhus fever to any great extent, the death-rates 
 for the latter could hardly have been so low as they were between 1833 and 1845, 
 before typhoid fever was recognized in the statistical nosology, or between 1851 
 and 1869, after this event. 
 
 SUMMARY. 
 
 The course of mortality for this group of diseases as a whole is best studied 
 by comparing the rates as averaged for 5-year periods (table 18, graph 3). 
 From an average rate of 288 for the period ending in 1815, the rates ascended 
 to 376 in 1816-1820 and 381 in 1821-1825. For the 10 years between 1816- 
 1825 the annual death toll from these diseases was then not far short of 400, 
 and during this time each member of the group reached the highest level 
 attained during the period under review. In the 5 years ending in 1830, the 
 picture completely changed, and, due to decreases in the rates for each separate 
 disease, the total rate sank to 145. With the continued absence of yellow fever, 
 at least as a recorded cause of death, and striking declines in the rates for both 
 malaria and typhus fever, the total rate continued to fall and by 1841-1845 it 
 had reached the comparatively low level of 59. Owing to a recrudescence of 
 typhus fever and in the face of an actual fall in the rate for malaria, the total 
 rate rose to 106 for the 5 years ending in 1850. During the next 5 years, in 
 spite of a return of yellow fever, the total rate fell by 50 per cent. Between 
 1855 and 1865 the average rate was about 25. Associated with a rise in the 
 rates of all three members of the group, the total rate ascended to 41 for the 
 succeeding 5 years, and for the 5 years ending in 1875 it averaged 56. In spite 
 of a slight turn of yellow fever, the total rate for 1876-1880 averaged only 20. 
 Due to a rise in the rate for malaria, the total rate rose to 26 during the 
 following five years. After 1885 the rate, with malaria now its sole contributor, 
 fell gradually to a negligible value in 1920. Typhus fever, responsible for a 
 large toll of deaths during the early part of the century, ran its course in 
 epidemic waves. The first was the longest and most severe. The last two were 
 comparatively mild, and each was less severe than its predecessor. In each 
 epidemic the disease pursued its way uninterfered with by restrictive measures. 
 Cases were not reported routinely, isolation and disinfection were not practiced, 
 and hospitalization was confined to the homeless and the very poor, who were 
 placed indiscriminately in the general wards. It may be said, then, that the 
 course of typhus fever in Baltimore, until very recent years, represented the 
 untrammeled reaction of the disease upon the population. Though recurring 
 with a few scattered cases repeatedly from time to time since the last epidemic, 
 the disease, in recognized form, has never gained a foothold, nevertheless, as has 
 been shown by the inspection of school children as late as 1915, a considerable 
 proportion of the population in various sections of the city was infested with 
 head lice. 
 
 In previous chapters it has been made clear enough that active administra¬ 
 tive measures were directed against nuisances of the type which favored the 
 recurrence and spread of malarial and yellow fevers. The correctness of their 
 
222 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 view that these diseases were not contagious in the usual sense and their erron¬ 
 eous belief that yellow fever was of local origin, and that both arose from 
 miasmata generated in stagnant water, combined to lead the authorities on the 
 right track in their efforts to combat them by sanitary measures. They pur¬ 
 sued their policy of securing dry cellars, of filling and draining low places, of 
 putting in drains, and of straightening and covering streams as best they 
 might, just as determinately and as rapidly, under the influence of the old 
 miasma theory, as they would have on the basis of correct information. So far 
 as the city was concerned, the difficulty lay in the fact that the problems 
 presented by rapidly expanding ocean commerce with infected localities, 
 exuberant population growth, and the topographical conditions were too great 
 to be rapidly overcome with the means at hand. Lack of knowledge concerning 
 the relation of mosquitoes to the propagation of these diseases was, of course, 
 a serious handicap that militated against their efforts in many respects. The 
 closed or almost closed docks at Fell’s Point and the extensive marshes on 
 each side and the pools of stagnant water on the point itself furnished ample 
 breeding-places for myriads of mosquitoes. Lazaretto Point, just southeast of 
 Fell’s Point, where until 1836 ships and cargoes were inspected, aired, and 
 cleansed and passengers and crews were detained, was nearly surrounded by 
 marshes and ponds. Thus conditions were ideal for the perennial propagation 
 of malaria in both its milder indigenous and its severer imported forms and of 
 yellow fever when imported from the tropics and from the southern parts of 
 the United States. It is probable that the great drop in mortality from the 
 mosquito-borne diseases between 1825 and 1830 was due in large measure to 
 sanitary improvements at Fell’s Point and about Lazaretto Point, and that 
 the further fall between 1835 and 1845 was to a considerable degree the result 
 of the destruction by fire in 1836, of the Government lazaretto with the conse¬ 
 quent abandonment of this place as an inspection-point for ocean shipping. 
 With the permanent establishment of quarantine inspection and detention at 
 Fairfield Point and later at Leading Point, as isolated, though mosquito- 
 infested localities situated further from the city, the chances of importing 
 pernicious malaria and yellow fever at the Fell’s Point and other city docks 
 must have been materially diminished, though, as the records show, by no 
 means closed. 
 
 That part of the city called Old Town, along the east side of Jones Falls, 
 and the territory of the city proper, situated along the west side of Jones 
 Falls and the basin, were in the early days second only to Fell’s Point as centers 
 of malaria. By the end of the first quarter of the nineteenth century consider¬ 
 able improvements had been accomplished in these localities also as the result 
 of straightening the course of the falls, filling in the marshes and other low 
 grounds, and grading and paving streets and laying gutters. Activities of this 
 character, together with improvements in the banks and channels of the lower 
 reaches of Harford, Schroeder’s and Rutter’s Runs and of Jones Falls were 
 prosecuted with vigor during the next 25 years. While these measures were 
 never pushed to a. state of completeness that entirely removed the conditions 
 essential to mosquito-breeding in the growing city, they were probably in 
 large part responsible for the fall in mortality from the mosquito-borne dis¬ 
 eases between 1835 and 1860. The slight reaction in the rate between 1850 
 
FEBRILE DISEASES 
 
 223 
 
 and 1855 was associated with the repeated importation of yellow fever. The 
 stationary state of the rate during the Civil War period, when commerce with 
 the West Indies, Central and South America, and the Confederate States was 
 cut off, suggests that the interference with the importation of malaria from 
 these sources was more than offset by spread to the general population of 
 malaria imported by Federal soldiers invalided from the armies fighting in 
 the Southern States. 
 
 The decided increase in mortality from malarial fever during the 10 years 
 subsequent to the Civil War was probably a direct reflection of the resumption 
 of communications with malarious countries and the returning soldiers, com¬ 
 bined with relaxation in the progress of sanitary measures connected with 
 drainage and the extensive ditching operations involved in the extension of 
 water-mains at this time. That malarial fever of severe grade was common at 
 this time in the newly built-up territory bordering the stagnant Harford Eun 
 is a matter of record. There is convincing evidence that the rise in the rates 
 for malaria between 1885 and 1890 was associated with infection of workers at 
 the steel works at Sparrows Point, where the disease in severe form was con¬ 
 stantly imported on ore-carrying vessels from Cuban ports. Between 1875 
 and 1890 all the large sewer streams except Jones Falls and the numerous 
 uncovered sewers were covered over, and an increasingly large proportion of 
 the inhabitants dwelt upon high ground. Between 1890 and 1920 the whole 
 physical surface of most of the city was gradually changed by sanitary improve¬ 
 ments which decreased the amount of standing water. However, in ravines, 
 in cans and other receptacles on ash dumps, and on the irregular surfaces of 
 ill-paved alleys, as late as 1920, there still remained opportunities for mosquito¬ 
 breeding. The ditching involved in the construction of the new sewerage system 
 between 1906 and 1915 gave ample opportunity for mosquito-breeding. Never¬ 
 theless, during this whole period since 1890 the death-rates from malaria con¬ 
 tinued to fall and before the special campaign to exterminate the mosquito was 
 instituted in 1910 they had reached negligible proportions. 
 
 These efforts continuously, though often but slowly and inffectually, put 
 forth by the city authorities to prevent and abate nuisances of the type that 
 favor the spread of the mosquito-borne diseases within the city were not the 
 sole agencies at work. It has been pointed out that the opportunities for the 
 direct importation into the city of malaria and yellow-fever cases and of mos¬ 
 quitoes infected with their causal agents were materially lessened by the 
 removal of the quarantine station to more distant points after 1836, though 
 until very recent years the quarantine never offered a complete barrier. Though 
 the decrease in the rate for yellow fever since 1876 must be credited in great 
 degree to the sanitary improvements and to greater efficacy of quarantine 
 measures, in large degree it must have been due to diminished prevalence of 
 the disease at ports of trade and to the falling-off of shipping. The same con¬ 
 siderations must apply also in large part to malaria. Especially important in 
 connection with the fall in the rates from the latter disease has been its 
 decrease in prevalence and severity in tidewater Maryland and Virginia, where 
 it was in former years so frequently contracted by visitors from the city and 
 whence it was constantly imported by visitors from the rural districts. All 
 
224 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 the considerable evidence at hand indicates that, significant as were the bene¬ 
 ficial results of administrative efforts of various kinds, the chief cause of the 
 decline in the mortality from malarial fever was the saturation of the popula¬ 
 tion with cinchona bark and its derivatives. 
 
 ACUTE INFLAMMATORY AFFECTIONS OF THE 
 INTESTINAL TRACT CHARACTERIZED BY 
 FREQUENT LOOSE STOOLS OF 
 ABNORMAL COMPOSITION. 
 
 The term “ inflammation ” is here used in a very wide sense to embrace 
 processes characterized by exudates composed largely of serum or plasma and 
 poor in corpuscular elements, and associated with little or even no apparent 
 loss of intestinal mucosa, as well as processes ranging from sero- and muco¬ 
 purulent exudations and desquamative lesions to the more severe inflammatory 
 lesions with abundant cellular exudations, hemorrhages, fibrous false mem¬ 
 branes, and proliferation and necrosis of tissue. 
 
 The affections now to be considered have long been recognized in both 
 medical and statistical nosology as having one conspicuous symptom in com¬ 
 mon—evacuations from the intestinal tract abnormal in frequency, amount, 
 and composition. The same affection has gone under various names at different 
 periods, as cholera morbus, cramp colic, and diarrhoea, for instance; and a 
 single term, as dysentery, has included several affections varying both in ana¬ 
 tomical lesions and in etiology. Affections apparently closely akin in causation 
 and in other relationships as well have been classified separately according to 
 the age of the victims, as cholera infantum for diarrhoea in infants and diar¬ 
 rhoea or one of its synonyms for similar disease in those over 2 years of age. 
 Two members of this statistical group, typhoid fever and Asiatic cholera, stand 
 out clearly both anatomically and causally as definite specific diseases; but even 
 these have been subject to much confusion with other numbers of the group. 
 On the contrary, dysentery, distinguished in its common clinical form by 
 characteristic pain in the lower bowel and by the frequent passage of stools 
 containing mucus, pus, and recognizable blood, is not a single anatomical and 
 etiological entity. The amoebic or so-called tropical dysentery due to Amoeba 
 histolytica and met with at one period in Baltimore, has peculiar necrotic 
 lesions resulting in typical ulcers in the rectum and colon; but it is by no 
 means always acute and is not invariably accompanied with the characteristic 
 rectal tenesmus and the purulent and bloody stools of the typical clinical 
 dysentery. In fact, this form of dysentery often takes a chronic course, with 
 alternate constipation and diarrhoea, and with stools resembling more closely 
 those of an ordinary diarrhoea than those of typical dysentery. The type of 
 clinical dysentery more common in temperate climates, and recognized since 
 1897 as caused by the bacillus of Shiga and its several varieties, and now 
 known as bacillary dysentery, has no characteristic anatomical lesion of the 
 intestine. The lesions vary in individual cases from simple congestion of the 
 intestinal mucosa and its lymph follicles to destruction, with ulceration of 
 both, with or without the deposit of fibrinous false-membranes. As will be 
 pointed out in greater detail later, a not inconsiderable proportion of the 
 deaths of infants classified under cholera infantum or summer complaint in 
 
FEBRILE DISEASES 
 
 225 
 
 Baltimore in recent years have been due to infection with B. dysenteries, with 
 consequent confusion of statistical data. A type of dysentery well known to 
 pathological anatomists as croupous or false-membranous dysentery and occur¬ 
 ring often, but by no means always, a‘s a complication of other diseases, is prob¬ 
 ably not always of specific etiology, but caused by a variety of bacteria, notably 
 streptococcus. Similar lesions of the rectum and colon occur in mercurial 
 poisoning. 
 
 Under this section may be traced a fourth statistical rubric, which for lack of 
 a better term will be called diarrhoea. Here are placed deaths classified under 
 cholera morbus, cramp colic, diarrhoea, inflammation of the bowels, cholera 
 infantum, and teething. According to the best available evidence, drawn from 
 the traditions of local medical and statistical nosology, the last two embrace 
 the deaths now classified under 104 of the present international classification 
 of causes of death—diarrhoea in persons under 2 years of age. For con¬ 
 venience this last group will be given the title in common usage in Baltimore, 
 cholera infantum. The other four headings, at different periods in the history 
 of the health department varying in relative importance in the statistical 
 nosology, represent the present rubric 105, or diarrhoea in persons over 2 
 years of age. As cholera morbus until 1821 carried most of the deaths for both 
 of these rubrics, the latter can not be separated with any degree of accuracy 
 before this date. As a matter of fact, there is serious reason for doubting that 
 classification between these two divisions of the diarrhceal affections ever 
 approached accuracy. 
 
 In this heterogenous group of affections called diarrhoea, the structural 
 lesions of the intestines present, in general, no characteristic features, and are 
 often insignificantly slight in proportion to the severity of the clinical symp¬ 
 toms. Hypersection of mucus, exudation of plasma in large amounts from the 
 vessels, changes in the bacterial flora of the intestines, with excessive fermenta¬ 
 tion and putrefaction and consequent changes in the character, consistency, 
 and frequency of the stools, and general prostration, often with rapid loss in 
 weight, are the prominent characteristics. In severe cases the picture is 
 strikingly similar to that of cholera, with which considerable confusion has 
 existed at times. 
 
 These diseases have in common a second important characteristic, viz, their 
 causes appear to be spread, chiefly at least, in the same way by means of foods 
 acting as vehicles of transmission. They constitute, therefore, the second divi¬ 
 sion of the nuisance diseases. In certain foods recognized as particularly good 
 vehicles, water, milk, etc., the causes of some of these diseases frequently find 
 opportunities favorable not only for prolonging existence, but for multiplying 
 rapidly. As the causal agents are given off from the body with the excreta,, it 
 is not surprising that water, the food most readily polluted with such materials 
 and the one universal food at all ages, should prove to be their most common 
 means of communication from person to person; and hence arises the fact that 
 in this group are found the best known examples of water-borne diseases. 
 Through foods infected directly or indirectly from previous cases seem to he 
 by far the most important vehicles of infection, an ever-increasing body of 
 evidence supports the opinion that, in many instances at least, and for 
 obvious reasons, the infecting agents are conveyed from person to person by 
 direct contact. Ample evidence in favor of possibilities of this mode of trans- 
 
226 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 mission is apparent when it is recalled that, in the natural course of events, 
 micro-organisms present in any considerable number in the excreta must gain 
 access by means of the garments to various parts of the body and finally to 
 the hands, at times at least, of the most fastidiously cleanly. However, in this 
 case, it is probable that in most instances the few organisms it is thus possible 
 to convey from one person’s hands to another’s mouth are not sufficient for an 
 infective dose and that successful conveyance of infection by hands usually 
 . requires the medium of some food material in which the micro-organisms 
 may first multiply. 
 
 For obvious reasons, the transmission of the causal agents of these affections 
 from the bowel discharges, and even in the case of some of them from the 
 urine, to human food by insects, and notably by flies, is not unusual. Not 
 uncommonly opportunity arises for the spread of some of them, particularly 
 amoebic dysentery, by means of fresh vegetables and fruits eaten raw, such as 
 cabbage, lettuce, cress, strawberries, and the like, which have been manured with 
 night-soil. Possibly for all, and certainly for some of them, the causal agents 
 persist in bowel and bladder discharges for varying periods after recovery. 
 Some of those who have had typhoid fever discharge B. typhosus in their urine 
 or feces many years after recovery. The chronic “ carrier ” exerts an important 
 influence upon the persistence in communities of some of these diseases, notably 
 typhoid fever and amoebic dysentery. Furthermore, for some of these, particu¬ 
 larly cholera, typhoid and para-typhoid fevers, and dysentery, the “ carrier ” 
 state may occasionally exist temporarily in persons who have never had clinical 
 manifestations of infection. Too little is known of the behavior in the outside 
 world of the causes of these diseases as a class to form an intelligent opinion 
 concerning the sources and means of infection unassociated directly or indirectly 
 with human beings as above outlined. At any rate, some of the most prominent, 
 as cholera, typhoid fever, and dysentery, have disappeared for considerable 
 periods of time when the chain of direct and indirect infection between human 
 beings has been broken. It would appear, therefore, that the human being as 
 a host forms a necessary link. 
 
 Even a cursory study of their history in Baltimore indicates that the pre¬ 
 valence and lethal force of the acute intestinal affections have been correlated 
 with movements of people, the age and social composition of the population, 
 natural conditions of and artificial interferences with the material environ¬ 
 ment, and medical care. It is only within comparatively recent years that 
 individual or personal efforts at their control have been put forth seriously. 
 To trace separately and in detail for each member of the group those particular 
 events in the social and sanitary history of the city that bear upon them all in 
 common would involve needless repetition and hopeless confusion. Clarity 
 will be gained by presenting the pertinent facts of the actual course of each 
 affection, particularly in regard to its lethal force over the whole period under 
 review, the relation of the various affections to each other and to the total 
 death-rates for the group, and the conditions which appear to have influenced 
 their course favorably or unfavorably. These acute intestinal affections natu¬ 
 rally fall under four statistical headings, as follows: Diarrhoeas—cholera 
 infantum (rubric 104) and diarrhoea (rubric 105) ; dysentery; Asiatic cholera; 
 typhoid fever. 
 
FEBRILE DISEASES 
 
 227 
 
 DIARRHCEAS. 
 
 The annual number of deaths ascribed to the heading cholera infantum 
 (rubric 104) in the local statistical nosology can not be ascertained before 
 1821, because they were included with that from cholera morbus. Indeed, it 
 would appear that it was some years later that the separation became sharply 
 cut. While in a general sense it is clear that, after 1824 at least, cholera infan¬ 
 tum, in the local statistical nosology, has meant the diarrhoeal affections of 
 infants below the completion of the second year of life, it is by no means certain 
 that it was consistently so restricted during all this long period of time. In 
 the special tables for this heading for 1901 to 1904, inclusive, the age period, 
 was given as “ under 5 years,” and it has been only since 1905 that the deaths 
 have been specified as “ under 2 years of age.” The course of diarrhoea (105) 
 (table 19, graph 5) in comparison with that of cholera infantum (104) between 
 1880 and 1898, when, on the whole, the former was rising or was holding a 
 high level and the latter w T as falling, suggests that some deaths of infants certi¬ 
 fied as due to diarrhoea were classified under this heading instead of under 
 cholera infantum. The sharp rise in the rate for cholera infantum after 1898, 
 associated with a correspondingly abrupt drop for diarrhoea, suggests changes 
 in custom of classification rather than in the relative number of deaths from 
 these two sets of causes. 
 
 Between 1812 and 1898 the records show continuously a variable but consid¬ 
 erable number of deaths attributed to teething, and during the long period of 
 excessively high rates for cholera infantum between 1845 and 1875 the number 
 of deaths classified under teething were specially numerous. On account of 
 the testimony of physicians in practice, and especially of some of those long 
 identified with the health department, that in the local nosology death from 
 teething was synomyous with death from cholera infantum in the mind of the 
 public and of many physicians, it has seemed necessary to include deaths under 
 this heading in the rubric for cholera infantum. With the adoption of the 
 international classification in 1899, teething as well as cholera infantum gave 
 place to rubric 104. There is evidence that in some cholera years confusion 
 between cholera asiatica and cholera infantum led to the assignment of deaths 
 from one to the other of these two categories. Finally, there is a large possi¬ 
 bility that, before 1899, deaths of children under 2 years of age reported as 
 dysentery may have been classified by statistical clerks under that rubric 
 instead of under cholera infantum, contrary to the custom obtaining since the 
 adoption of the international classification. 
 
 To few diseases of common occurrence and high fatality has intensive study 
 over a long period of years yielded less in accurate knowledge of direct causation 
 than the gastro-enteritis or diarrhoea of infants. In spite of the large body of 
 valuable information gained in regard to predisposing causes as ill care, unsuit¬ 
 able foods, heat and humidity, cold, the characteristics of the stools, pathological 
 anatomy and general pathology, preventive measures (the use of mother’s milk, 
 properly prepared and selected cow’s milk, and other foods), the scientific 
 general care of infants, and even medical treatment, definite knowledge of the 
 actual or determinative causes is lacking. Whereas it has long been known 
 that at the same or at different dates there is great difference in the character 
 of the stools of affected infants, particularly in regard to the presence or absence 
 
228 
 
 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 Table 19 .—Number of deaths and rate of death, per 100,000 living inhabitants, from diarrhoea, 
 dysentery, cholera, and typhoid fever, and the percentage of total acute inflammatory in¬ 
 fections of the intestinal tract of total deaths, from 1812 to 1920, inclusive. 
 
 D = death. R = rate. 
 
 Diarrhoea. 
 
 Diarrhoea, under 2 years of age. 
 
 Diarrhoea, 2 years of age and over. 
 
 Year. 
 
 Cholera 
 
 infantum. 
 
 Teething. 
 
 Total. 
 
 Cholera 
 
 morbus. 
 
 Cramp 
 
 colic. 
 
 Diar¬ 
 
 rhoea. 
 
 Inflam¬ 
 mation of 
 bowels. 
 
 Total. 
 
 Total. 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 1812 
 
 • % 
 
 
 
 2 
 
 5 
 
 2 
 
 5 
 
 174 
 
 425 
 
 8 
 
 20 
 
 1 
 
 2 
 
 
 • • • 
 
 183 
 
 447 
 
 185 
 
 452 
 
 1813 
 
 • • 
 
 
 
 6 
 
 14 
 
 6 
 
 14 
 
 179 
 
 418 
 
 11 
 
 26 
 
 
 
 
 • • • 
 
 190 
 
 444 
 
 196 
 
 458 
 
 1814 
 
 • • 
 
 
 
 4 
 
 9 
 
 4 
 
 9 
 
 102 
 
 228 
 
 18 
 
 40 
 
 
 
 
 • • • 
 
 120 
 
 268 
 
 124 
 
 277 
 
 1815 
 
 • • 
 
 
 
 9 
 
 19 
 
 9 
 
 19 
 
 167 
 
 357 
 
 8 
 
 17 
 
 
 
 
 • • • 
 
 175 
 
 374 
 
 184 
 
 394 
 
 1816 
 
 • • 
 
 
 
 3 
 
 6 
 
 3 
 
 6 
 
 132 
 
 270 
 
 16 
 
 33 
 
 
 
 
 • • • 
 
 148 
 
 303 
 
 151 
 
 309 
 
 1817 
 
 • • 
 
 
 
 9 
 
 18 
 
 9 
 
 18 
 
 214 
 
 420 
 
 9 
 
 18 
 
 
 
 
 • • • 
 
 223 
 
 438 
 
 232 
 
 455 
 
 1818 
 
 • • 
 
 
 
 16 
 
 30 
 
 16 
 
 30 
 
 280 
 
 526 
 
 15 
 
 28 
 
 
 
 4 
 
 8 
 
 299 
 
 562 
 
 315 
 
 592 
 
 1819 
 
 • • 
 
 
 
 27 
 
 49 
 
 27 
 
 49 
 
 121 
 
 218 
 
 4 
 
 7 
 
 
 
 1 
 
 2 
 
 126 
 
 227 
 
 153 
 
 276 
 
 1820 
 
 • • 
 
 
 
 20 
 
 35 
 
 20 
 
 35 
 
 175 
 
 302 
 
 17 
 
 29 
 
 2 
 
 3 
 
 5 
 
 9 
 
 199 
 
 344 
 
 219 
 
 379 
 
 1821 
 
 • • 
 
 197 
 
 327 
 
 9 
 
 15 
 
 206 
 
 342 
 
 12 
 
 20 
 
 26 
 
 43 
 
 10 
 
 17 
 
 2 
 
 3 
 
 50 
 
 83 
 
 256 
 
 425 
 
 1822 
 
 • • 
 
 260 
 
 414 
 
 16 
 
 25 
 
 276 
 
 439 
 
 5 
 
 8 
 
 15 
 
 24 
 
 9 
 
 14 
 
 1 
 
 2 
 
 30 
 
 48 
 
 306 
 
 487 
 
 1823 
 
 • • 
 
 253 
 
 387 
 
 13 
 
 20 
 
 266 
 
 407 
 
 • • • 
 
 • • • 
 
 9 
 
 14 
 
 • • • 
 
 • • • 
 
 6 
 
 9 
 
 15 
 
 23 
 
 281 
 
 430 
 
 1824 
 
 • • 
 
 90 
 
 132 
 
 4 
 
 6 
 
 94 
 
 138 
 
 5 
 
 7 
 
 11 
 
 16 
 
 1 
 
 1 
 
 8 
 
 12 
 
 25 
 
 37 
 
 119 
 
 175 
 
 1825 
 
 • • 
 
 93 
 
 131 
 
 14 
 
 20 
 
 107 
 
 151 
 
 7 
 
 10 
 
 17 
 
 24 
 
 37 
 
 52 
 
 • • • 
 
 • • • 
 
 61 
 
 86 
 
 168 
 
 237 
 
 1826 
 
 • • 
 
 119 
 
 162 
 
 8 
 
 11 
 
 127 
 
 172 
 
 11 
 
 15 
 
 17 
 
 23 
 
 • • • 
 
 • • • 
 
 1 
 
 1 
 
 29 
 
 39 
 
 156 
 
 212 
 
 1827 
 
 • • 
 
 77 
 
 101 
 
 11 
 
 14 
 
 88 
 
 115 
 
 12 
 
 16 
 
 13 
 
 17 
 
 • • • 
 
 • • • 
 
 6 
 
 8 
 
 31 
 
 40 
 
 119 
 
 155 
 
 1828 
 
 • • 
 
 110 
 
 138 
 
 16 
 
 20 
 
 126 
 
 158 
 
 9 
 
 11 
 
 7 
 
 9 
 
 1 
 
 1 
 
 10 
 
 13 
 
 27 
 
 34 
 
 153 
 
 192 
 
 1829 
 
 • • 
 
 140 
 
 170 
 
 1 
 
 1 
 
 141 
 
 171 
 
 7 
 
 8 
 
 15 
 
 18 
 
 • * • 
 
 • • • 
 
 8 
 
 10 
 
 30 
 
 36 
 
 171 
 
 207 
 
 1830 
 
 • • 
 
 182 
 
 212 
 
 8 
 
 9 
 
 190 
 
 222 
 
 40 
 
 47 
 
 7 
 
 8 
 
 • • • 
 
 • • • 
 
 10 
 
 12 
 
 57 
 
 67 
 
 247 
 
 288 
 
 1831 
 
 • • 
 
 248 
 
 279 
 
 18 
 
 20 
 
 266 
 
 299 
 
 9 
 
 10 
 
 9 
 
 10 
 
 3 
 
 3 
 
 7 
 
 8 
 
 28 
 
 32 
 
 294 
 
 331 
 
 1832 
 
 • • 
 
 332 
 
 360 
 
 16 
 
 17 
 
 348 
 
 378 
 
 2 
 
 2 
 
 22 
 
 24 
 
 1 
 
 1 
 
 17 
 
 18 
 
 42 
 
 46 
 
 390 
 
 423 
 
 1833 
 
 • • 
 
 146 
 
 153 
 
 17 
 
 18 
 
 163 
 
 171 
 
 2 
 
 2 
 
 8 
 
 8 
 
 • • • 
 
 • • • 
 
 22 
 
 23 
 
 32 
 
 34 
 
 195 
 
 204 
 
 1834 
 
 • • 
 
 201 
 
 203 
 
 23 
 
 23 
 
 224 
 
 226 
 
 35 
 
 35 
 
 23 
 
 23 
 
 1 
 
 1 
 
 14 
 
 14 
 
 73 
 
 74 
 
 297 
 
 300 
 
 1835 
 
 • • 
 
 89 
 
 87 
 
 23 
 
 22 
 
 112 
 
 109 
 
 5 
 
 5 
 
 10 
 
 10 
 
 • • • 
 
 • • • 
 
 15 
 
 15 
 
 30 
 
 29 
 
 142 
 
 139 
 
 1836 
 
 • • 
 
 191 
 
 180 
 
 16 
 
 15 
 
 207 
 
 195 
 
 2 
 
 2 
 
 6 
 
 6 
 
 2 
 
 2 
 
 15 
 
 14 
 
 25 
 
 24 
 
 232 
 
 219 
 
 1837 
 
 • • 
 
 131 
 
 120 
 
 28 
 
 26 
 
 159 
 
 145 
 
 • • • 
 
 • • • 
 
 9 
 
 8 
 
 • • • 
 
 • • • 
 
 10 
 
 9 
 
 19 
 
 17 
 
 178 
 
 162 
 
 1838 
 
 • • 
 
 199 
 
 176 
 
 21 
 
 19 
 
 220 
 
 194 
 
 2 
 
 2 
 
 4 
 
 4 
 
 • • • 
 
 • • • 
 
 14 
 
 12 
 
 20 
 
 18 
 
 240 
 
 212 
 
 1839 
 
 • • 
 
 125 
 
 107 
 
 15 
 
 13 
 
 140 
 
 120 
 
 2 
 
 2 
 
 3 
 
 3 
 
 1 
 
 1 
 
 20 
 
 17 
 
 26 
 
 22 
 
 166 
 
 142 
 
 1840 
 
 • • 
 
 114 
 
 94 
 
 21 
 
 17 
 
 135 
 
 112 
 
 1 
 
 1 
 
 7 
 
 6 
 
 • • • 
 
 • • • 
 
 21 
 
 17 
 
 29 
 
 24 
 
 164 
 
 136 
 
 1841 
 
 • • 
 
 194 
 
 155 
 
 28 
 
 22 
 
 222 
 
 178 
 
 • • • 
 
 • • • 
 
 4 
 
 3 
 
 • • • 
 
 • • • 
 
 36 
 
 29 
 
 40 
 
 32 
 
 262 
 
 210 
 
 1842 
 
 • • 
 
 198 
 
 154 
 
 29 
 
 22 
 
 227 
 
 176 
 
 9 
 
 7 
 
 4 
 
 3 
 
 2 
 
 2 
 
 46 
 
 36 
 
 61 
 
 47 
 
 288 
 
 223 
 
 1843 
 
 • • 
 
 159 
 
 119 
 
 29 
 
 22 
 
 188 
 
 141 
 
 8 
 
 6 
 
 10 
 
 8 
 
 • • • 
 
 • • • 
 
 46 
 
 35 
 
 64 
 
 48 
 
 252 
 
 189 
 
 1844 
 
 • • 
 
 129 
 
 94 
 
 16 
 
 12 
 
 145 
 
 106 
 
 6 
 
 4 
 
 5 
 
 4 
 
 1 
 
 1 
 
 37 
 
 27 
 
 49 
 
 36 
 
 194 
 
 141 
 
 1845 
 
 • • 
 
 113 
 
 80 
 
 19 
 
 13 
 
 132 
 
 93 
 
 7 
 
 5 
 
 12 
 
 8 
 
 • • • 
 
 • • • 
 
 34 
 
 24 
 
 53 
 
 37 
 
 185 
 
 131 
 
 1846 
 
 • • 
 
 139 
 
 95 
 
 42 
 
 29 
 
 181 
 
 124 
 
 4 
 
 3 
 
 8 
 
 5 
 
 • • • 
 
 • • • 
 
 51 
 
 35 
 
 63 
 
 43 
 
 244 
 
 167 
 
 1847 
 
 • • 
 
 249 
 
 166 
 
 69 
 
 46 
 
 318 
 
 212 
 
 • • • 
 
 • • • 
 
 4 
 
 3 
 
 7 
 
 5 
 
 60 
 
 40 
 
 71 
 
 47 
 
 389 
 
 259 
 
 1848 
 
 • • 
 
 244 
 
 158 
 
 92 
 
 59 
 
 336 
 
 217 
 
 • • • 
 
 • • • 
 
 6 
 
 4 
 
 15 
 
 10 
 
 67 
 
 43 
 
 88 
 
 57 
 
 424 
 
 274 
 
 1849 
 
 • • 
 
 290 
 
 182 
 
 102 
 
 64 
 
 392 
 
 246 
 
 32 
 
 20 
 
 9 
 
 6 
 
 69 
 
 43 
 
 46 
 
 29 
 
 156 
 
 98 
 
 548 
 
 344 
 
 1850 
 
 • • 
 
 347 
 
 212 
 
 99 
 
 60 
 
 446 
 
 272 
 
 27 
 
 16 
 
 9 
 
 5 
 
 40 
 
 24 
 
 54 
 
 33 
 
 130 
 
 79 
 
 576 
 
 351 
 
 1851 
 
 • • 
 
 290 
 
 172 
 
 93 
 
 55 
 
 383 
 
 227 
 
 6 
 
 4 
 
 11 
 
 7 
 
 15 
 
 9 
 
 66 
 
 39 
 
 98 
 
 58 
 
 481 
 
 285 
 
 1852 
 
 • • 
 
 339 
 
 195 
 
 120 
 
 69 
 
 459 
 
 265 
 
 10 
 
 6 
 
 13 
 
 8 
 
 49 
 
 28 
 
 78 
 
 45 
 
 150 
 
 86 
 
 609 
 
 351 
 
 1853 
 
 • • 
 
 256 
 
 144 
 
 94 
 
 53 
 
 350 
 
 196 
 
 11 
 
 6 
 
 28 
 
 16 
 
 34 
 
 19 
 
 80 
 
 45 
 
 153 
 
 86 
 
 503 
 
 282 
 
 1854 
 
 • • 
 
 395 
 
 216 
 
 114 
 
 62 
 
 509 
 
 278 
 
 129 
 
 70 
 
 111 
 
 61 
 
 39 
 
 21 
 
 55 
 
 30 
 
 334 
 
 182 
 
 843 
 
 460 
 
 1855 
 
 • • 
 
 418 
 
 222 
 
 169 
 
 90 
 
 587 
 
 312 
 
 22 
 
 12 
 
 22 
 
 12 
 
 30 
 
 16 
 
 88 
 
 47 
 
 162 
 
 86 
 
 749 
 
 398 
 
 1856 
 
 • • 
 
 568 
 
 294 
 
 206 
 
 107 
 
 774 
 
 400 
 
 14 
 
 7 
 
 11 
 
 6 
 
 6 
 
 3 
 
 88 
 
 46 
 
 119 
 
 62 
 
 893 
 
 462 
 
 1857 
 
 • • 
 
 410 
 
 207 
 
 206 
 
 104 
 
 616 
 
 310 
 
 12 
 
 6 
 
 24 
 
 12 
 
 14 
 
 7 
 
 74 
 
 37 
 
 124 
 
 62 
 
 740 
 
 373 
 
 1858 
 
 • • 
 
 361 
 
 177 
 
 210 
 
 103 
 
 571 
 
 280 
 
 10 
 
 5 
 
 32 
 
 16 
 
 7 
 
 3 
 
 87 
 
 43 
 
 136 
 
 67 
 
 707 
 
 347 
 
 1859 
 
 • • 
 
 386 
 
 185 
 
 163 
 
 78 
 
 549 
 
 263 
 
 17 
 
 8 
 
 21 
 
 10 
 
 16 
 
 8 
 
 68 
 
 33 
 
 122 
 
 58 
 
 671 
 
 321 
 
 1860 
 
 • • 
 
 328 
 
 153 
 
 204 
 
 95 
 
 532 
 
 248 
 
 13 
 
 6 
 
 25 
 
 12 
 
 6 
 
 3 
 
 84 
 
 39 
 
 128 
 
 60 
 
 660 
 
 308 
 
 1861 
 
 • • 
 
 325 
 
 148 
 
 225 
 
 102 
 
 550 
 
 250 
 
 8 
 
 4 
 
 48 
 
 22 
 
 8 
 
 4 
 
 63 
 
 29 
 
 127 
 
 58 
 
 677 
 
 308 
 
 1862 
 
 • • 
 
 266 
 
 118 
 
 157 
 
 70 
 
 423 
 
 188 
 
 13 
 
 6 
 
 57 
 
 25 
 
 15 
 
 7 
 
 55 
 
 24 
 
 140 
 
 62 
 
 563 
 
 250 
 
 1863 
 
 • • 
 
 287 
 
 124 
 
 157 
 
 68 
 
 444 
 
 192 
 
 13 
 
 6 
 
 77 
 
 33 
 
 13 
 
 6 
 
 57 
 
 25 
 
 160 
 
 69 
 
 604 
 
 261 
 
 1864 
 
 • • 
 
 309 
 
 130 
 
 150 
 
 63 
 
 459 
 
 194 
 
 10 
 
 4 
 
 87 
 
 37 
 
 9 
 
 4 
 
 68 
 
 29 
 
 174 
 
 73 
 
 633 
 
 267 
 
 1865 
 
 • • 
 
 285 
 
 117 
 
 112 
 
 46 
 
 397 
 
 164 
 
 30 
 
 12 
 
 79 
 
 33 
 
 21 
 
 9 
 
 61 
 
 25 
 
 191 
 
 79 
 
 588 
 
 242 
 
 1866 
 
 • • 
 
 340 
 
 137 
 
 151 
 
 61 
 
 491 
 
 198 
 
 40 
 
 16 
 
 109 
 
 44 
 
 21 
 
 8 
 
 41 
 
 17 
 
 211 
 
 85 
 
 702 
 
 283 
 
FEBRILE DISEASES 
 
 229 
 
 Table 19 .—Number of deaths and rate of death, per 100,000 living inhabitants, from diarrhoea, 
 
 dysentery, cholera, and typhoid fever, etc. —Continued. 
 
 D = death. R = rate. 
 
 Diarrhoea. 
 
 Diarrhoea, under 2 years of age. 
 
 Diarrhoea, 2 years of age and over. 
 
 Year. 
 
 Cholera 
 
 infantum. 
 
 Teething. 
 
 Total. 
 
 Cholera 
 
 morbus. 
 
 Cramp 
 
 colic. 
 
 Diar¬ 
 
 rhoea. 
 
 Inflam¬ 
 mation of 
 bowels. 
 
 Total. 
 
 Total. 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 1867 
 
 • • 
 
 257 
 
 101 
 
 230 
 
 90 
 
 487 
 
 191 
 
 14 
 
 6 
 
 159 
 
 62 
 
 6 
 
 2 
 
 51 
 
 20 
 
 230 
 
 90 
 
 717 
 
 282 
 
 1868 
 
 • • 
 
 356 
 
 137 
 
 307 
 
 118 
 
 663 
 
 255 
 
 17 
 
 7 
 
 153 
 
 59 
 
 8 
 
 3 
 
 40 
 
 15 
 
 218 
 
 84 
 
 881 
 
 338 
 
 1869 
 
 • • 
 
 332 
 
 125 
 
 284 
 
 107 
 
 616 
 
 231 
 
 23 
 
 9 
 
 121 
 
 45 
 
 10 
 
 4 
 
 61 
 
 23 
 
 215 
 
 81 
 
 831 
 
 312 
 
 1870 
 
 • • 
 
 450 
 
 165 
 
 272 
 
 100 
 
 722 
 
 265 
 
 20 
 
 7 
 
 195 
 
 72 
 
 4 
 
 1 
 
 52 
 
 19 
 
 271 
 
 99 
 
 993 
 
 364 
 
 1871 
 
 • • 
 
 286 
 
 103 
 
 226 
 
 81 
 
 512 
 
 184 
 
 23 
 
 8 
 
 215 
 
 77 
 
 12 
 
 4 
 
 52 
 
 19 
 
 302 
 
 108 
 
 814 
 
 292 
 
 1872 
 
 • • 
 
 638 
 
 224 
 
 293 
 
 103 
 
 931 
 
 326 
 
 39 
 
 14 
 
 60 
 
 21 
 
 9 
 
 3 
 
 69 
 
 24 
 
 177 
 
 62 
 
 1108 
 
 388 
 
 1873 
 
 • • 
 
 598 
 
 205 
 
 274 
 
 94 
 
 872 
 
 299 
 
 26 
 
 9 
 
 
 
 15 
 
 5 
 
 122 
 
 42 
 
 163 
 
 56 
 
 1035 
 
 355 
 
 1874 
 
 • • 
 
 766 
 
 257 
 
 284 
 
 95 
 
 1050 
 
 352 
 
 23 
 
 8 
 
 • • • 
 
 
 13 
 
 4 
 
 176 
 
 59 
 
 212 
 
 71 
 
 1262 
 
 423 
 
 1875 
 
 • • 
 
 643 
 
 211 
 
 119 
 
 39 
 
 762 
 
 250 
 
 22 
 
 7 
 
 • • • 
 
 
 97 
 
 32 
 
 73 
 
 24 
 
 192 
 
 63 
 
 954 
 
 313 
 
 1876 
 
 • • 
 
 702 
 
 226 
 
 136 
 
 44 
 
 838 
 
 269 
 
 24 
 
 8 
 
 • • • 
 
 
 147 
 
 47 
 
 79 
 
 25 
 
 250 
 
 80 
 
 1088 
 
 350 
 
 1877 
 
 • • 
 
 615 
 
 193 
 
 143 
 
 45 
 
 758 
 
 238 
 
 16 
 
 5 
 
 • • • 
 
 
 136 
 
 43 
 
 89 
 
 28 
 
 241 
 
 76 
 
 999 
 
 314 
 
 1878 
 
 • • 
 
 343 
 
 106 
 
 79 
 
 24 
 
 422 
 
 130 
 
 14 
 
 4 
 
 • • • 
 
 
 164 
 
 51 
 
 35 
 
 11 
 
 213 
 
 66 
 
 635 
 
 196 
 
 1879 
 
 • • 
 
 475 
 
 143 
 
 98 
 
 30 
 
 573 
 
 172 
 
 18 
 
 5 
 
 • • • 
 
 
 160 
 
 48 
 
 40 
 
 12 
 
 218 
 
 66 
 
 791 
 
 239 
 
 1880 
 
 • • 
 
 503 
 
 149 
 
 104 
 
 31 
 
 607 
 
 179 
 
 25 
 
 7 
 
 • • • 
 
 
 120 
 
 35 
 
 63 
 
 19 
 
 208 
 
 61 
 
 815 
 
 241 
 
 1881 
 
 • • 
 
 558 
 
 161 
 
 115 
 
 33 
 
 673 
 
 195 
 
 34 
 
 10 
 
 • • • 
 
 
 221 
 
 64 
 
 61 
 
 18 
 
 316 
 
 91 
 
 989 
 
 286 
 
 1882 
 
 • • 
 
 399 
 
 113 
 
 87 
 
 25 
 
 486 
 
 138 
 
 23 
 
 7 
 
 • • • 
 
 
 166 
 
 47 
 
 62 
 
 18 
 
 251 
 
 71 
 
 737 
 
 209 
 
 1883 
 
 • • 
 
 473 
 
 131 
 
 91 
 
 25 
 
 564 
 
 157 
 
 18 
 
 5 
 
 • • • 
 
 
 167 
 
 46 
 
 62 
 
 17 
 
 247 
 
 69 
 
 811 
 
 225 
 
 1884 
 
 • • 
 
 496 
 
 135 
 
 104 
 
 28 
 
 600 
 
 163 
 
 16 
 
 4 
 
 9 0 0 
 
 
 240 
 
 65 
 
 56 
 
 15 
 
 312 
 
 85 
 
 912 
 
 248 
 
 1885 
 
 • • 
 
 498 
 
 133 
 
 99 
 
 26 
 
 597 
 
 159 
 
 28 
 
 7 
 
 0 9 0 
 
 
 186 
 
 50 
 
 56 
 
 15 
 
 270 
 
 72 
 
 867 
 
 232 
 
 1886 
 
 • • 
 
 485 
 
 127 
 
 98 
 
 26 
 
 583 
 
 153 
 
 13 
 
 3 
 
 0 0 0 
 
 
 238 
 
 62 
 
 65 
 
 17 
 
 316 
 
 83 
 
 899 
 
 235 
 
 1887 
 
 • • 
 
 567 
 
 146 
 
 111 
 
 29 
 
 678 
 
 174 
 
 29 
 
 *7 
 
 • 00 
 
 
 277 
 
 71 
 
 85 
 
 22 
 
 391 
 
 100 
 
 1069 
 
 275 
 
 1888 
 
 • • 
 
 651 
 
 155 
 
 105 
 
 25 
 
 756 
 
 180 
 
 30 
 
 7 
 
 • 09 
 
 
 330 
 
 79 
 
 79 
 
 19 
 
 439 
 
 105 
 
 1195 
 
 285 
 
 1889 
 
 • • 
 
 572 
 
 134 
 
 99 
 
 23 
 
 671 
 
 157 
 
 24 
 
 6 
 
 • 09 
 
 
 374 
 
 88 
 
 76 
 
 18 
 
 474 
 
 111 
 
 1145 
 
 263 
 
 1890 
 
 • • 
 
 507 
 
 117 
 
 128 
 
 29 
 
 635 
 
 146 
 
 23 
 
 5 
 
 • 00 
 
 
 418 
 
 96 
 
 105 
 
 24 
 
 546 
 
 126 
 
 1181 
 
 272 
 
 1891 
 
 • • 
 
 531 
 
 120 
 
 102 
 
 23 
 
 633 
 
 143 
 
 27 
 
 6 
 
 • 00 
 
 
 342 
 
 77 
 
 70 
 
 16 
 
 439 
 
 99 
 
 1072 
 
 243 
 
 1892 
 
 • • 
 
 661 
 
 147 
 
 126 
 
 28 
 
 787 
 
 175 
 
 29 
 
 6 
 
 • •• 
 
 
 445 
 
 99 
 
 104 
 
 23 
 
 578 
 
 129 
 
 1365 
 
 304 
 
 1893 
 
 • • 
 
 444 
 
 97 
 
 112 
 
 25 
 
 556 
 
 122 
 
 35 
 
 8 
 
 • 00 
 
 
 351 
 
 77 
 
 91 
 
 20 
 
 477 
 
 104 
 
 1033 
 
 226 
 
 1894 
 
 • • 
 
 440 
 
 95 
 
 77 
 
 17 
 
 517 
 
 111 
 
 18 
 
 4 
 
 • 00 
 
 
 419 
 
 90 
 
 72 
 
 16 
 
 509 
 
 110 
 
 1026 
 
 221 
 
 1895 
 
 • • 
 
 510 
 
 108 
 
 95 
 
 20 
 
 605 
 
 129 
 
 17 
 
 4 
 
 • 90 
 
 
 400 
 
 85 
 
 77 
 
 16 
 
 494 
 
 105 
 
 1099 
 
 233 
 
 1896 
 
 • • 
 
 412 
 
 86 
 
 68 
 
 14 
 
 480 
 
 100 
 
 22 
 
 5 
 
 • 00 
 
 
 373 
 
 78 
 
 92 
 
 19 
 
 487 
 
 102 
 
 967 
 
 202 
 
 1897 
 
 • • 
 
 401 
 
 83 
 
 75 
 
 15 
 
 476 
 
 98 
 
 14 
 
 3 
 
 • 00 
 
 
 410 
 
 84 
 
 80 
 
 16 
 
 504 
 
 104 
 
 980 
 
 202 
 
 1898 
 
 • • 
 
 386 
 
 78 
 
 65 
 
 13 
 
 451 
 
 91 
 
 12 
 
 2 
 
 • 00 
 
 
 490 
 
 99 
 
 18 
 
 4 
 
 520 
 
 105 
 
 971 
 
 197 
 
 1899 
 
 • • 
 
 703 
 
 141 
 
 • • • 
 
 
 703 
 
 141 
 
 16 
 
 3 
 
 • 00 
 
 
 165 
 
 38 
 
 • • • 
 
 
 181 
 
 36 
 
 884 
 
 177 
 
 1900 
 
 • • 
 
 848 
 
 167 
 
 • • • 
 
 
 848 
 
 167 
 
 6 
 
 1 
 
 • 00 
 
 
 105 
 
 21 
 
 • • • 
 
 
 111 
 
 22 
 
 959 
 
 189 
 
 1901 
 
 • • 
 
 726 
 
 141 
 
 • • • 
 
 
 726 
 
 141 
 
 7 
 
 1 
 
 • 00 
 
 
 88 
 
 17 
 
 • 00 
 
 
 95 
 
 18 
 
 821 
 
 160 
 
 1902 
 
 • • 
 
 695 
 
 133 
 
 • • • 
 
 
 695 
 
 133 
 
 16 
 
 3 
 
 • 00 
 
 
 82 
 
 16 
 
 • 00 
 
 
 98 
 
 19 
 
 793 
 
 152 
 
 1903 
 
 • • 
 
 550 
 
 104 
 
 • • • 
 
 
 550 
 
 104 
 
 8 
 
 2 
 
 • • • 
 
 
 68 
 
 13 
 
 • • • 
 
 
 76 
 
 14 
 
 626 
 
 119 
 
 1904 
 
 • • 
 
 671 
 
 126 
 
 • • • 
 
 
 671 
 
 126 
 
 6 
 
 1 
 
 • • • 
 
 
 72 
 
 13 
 
 • • • 
 
 
 78 
 
 15 
 
 749 
 
 140 
 
 1905 
 
 • • 
 
 751 
 
 139 
 
 • • • 
 
 
 751 
 
 139 
 
 4 
 
 1 
 
 • • • 
 
 
 86 
 
 16 
 
 • • • 
 
 
 90 
 
 17 
 
 841 
 
 156 
 
 1906 
 
 • • 
 
 623 
 
 114 
 
 • • • 
 
 
 623 
 
 114 
 
 4 
 
 1 
 
 • • • 
 
 
 86 
 
 16 
 
 • 00 
 
 
 90 
 
 16 
 
 713 
 
 130 
 
 1907 
 
 
 747 
 
 135 
 
 • • • 
 
 
 747 
 
 135 
 
 11 
 
 2 
 
 • • • 
 
 
 122 
 
 22 
 
 • 00 
 
 
 133 
 
 24 
 
 880 
 
 159 
 
 1908 
 
 
 591 
 
 106 
 
 • • • 
 
 
 591 
 
 106 
 
 15 
 
 3 
 
 • 00 
 
 
 109 
 
 19 
 
 • 00 
 
 
 124 
 
 22 
 
 715 
 
 128 
 
 1909 
 
 
 562 
 
 99 
 
 • • • 
 
 
 562 
 
 99 
 
 5 
 
 1 
 
 • 00 
 
 
 119 
 
 21 
 
 • • • 
 
 
 124 
 
 22 
 
 686 
 
 121 
 
 1910 
 
 • • 
 
 598 
 
 105 
 
 • • • 
 
 
 598 
 
 105 
 
 6 
 
 1 
 
 • • • 
 
 
 113 
 
 20 
 
 • • • 
 
 
 119 
 
 21 
 
 717 
 
 125 
 
 1911 
 
 
 568 
 
 98 
 
 • • • 
 
 
 568 
 
 98 
 
 3 
 
 1 
 
 . . . 
 
 
 83 
 
 14 
 
 • • • 
 
 
 86 
 
 15 
 
 654 
 
 113 
 
 1912 
 
 • • 
 
 501 
 
 86 
 
 • • • 
 
 
 501 
 
 86 
 
 3 
 
 1 
 
 . . . 
 
 
 88 
 
 15 
 
 • • • 
 
 
 91 
 
 16 
 
 592 
 
 101 
 
 1913 
 
 # # 
 
 558 
 
 95 
 
 • • • 
 
 
 558 
 
 95 
 
 2 
 
 
 . . . 
 
 
 83 
 
 14 
 
 • • • 
 
 
 85 
 
 14 
 
 643 
 
 109 
 
 1914 
 
 • * 
 
 564 
 
 95 
 
 • • • 
 
 
 564 
 
 95 
 
 
 
 . . . 
 
 
 78 
 
 13 
 
 • • • 
 
 
 78 
 
 13 
 
 642 
 
 108 
 
 1915 
 
 • • 
 
 480 
 
 80 
 
 • • • 
 
 
 480 
 
 80 
 
 
 
 
 
 91 
 
 15 
 
 • 90 
 
 
 91 
 
 15 
 
 571 
 
 95 
 
 1916 
 
 • • 
 
 581 
 
 96 
 
 • • • 
 
 
 581 
 
 96 
 
 
 
 
 
 83 
 
 14 
 
 . . . 
 
 
 83 
 
 14 
 
 664 
 
 109 
 
 1917 
 
 • 
 
 • • 
 
 635 
 
 104 
 
 • • • 
 
 
 635 
 
 104 
 
 
 
 . . . 
 
 
 101 
 
 16 
 
 • • • 
 
 
 101 
 
 16 
 
 736 
 
 120 
 
 1918 
 
 • • 
 
 795 
 
 129 ' 
 
 • • • 
 
 
 795 
 
 129 
 
 
 
 
 
 143 
 
 23 
 
 • • • 
 
 
 143 
 
 23 
 
 938 
 
 152 
 
 1919 
 
 • • 
 
 616 
 
 85 
 
 • • • 
 
 
 616 
 
 85 
 
 
 
 . . . 
 
 
 134 
 
 19 
 
 • • • 
 
 
 134 
 
 19 | 
 
 750 
 
 104 
 
 1920 
 
 •• 
 
 663 
 
 90 l 
 
 ... 
 
 
 663 
 
 90 
 
 
 
 . . . 
 
 ... 
 
 105 
 
 14 
 
 . . . 
 
 ... 
 
 105 
 
 14 
 
 768 
 
 105 
 
230 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 Table 19. —Number of deaths and rate of death, per 100,000 living inhabitants, from diarrhoea, 
 
 dysentery, cholera, and typhoid fever, etc. —Continued. 
 
 D = death. R = rate. 
 
 Year. 
 
 Dysen¬ 
 
 tery. 
 
 Cholera. 
 
 Typhoid fever. 
 
 Grand 
 
 total. 
 
 Per 
 
 cent. 
 
 of 
 
 total 
 
 deaths. 
 
 Nervous 
 
 fever. 
 
 Gastric 
 
 fever. 
 
 Typho- 
 
 malarial 
 
 fever. 
 
 Typhoid 
 
 fever. 
 
 Total. 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 1812 
 
 
 
 
 
 
 2 
 
 5 
 
 
 
 
 
 
 
 2 
 
 5 
 
 187 
 
 457 
 
 16 
 
 1813 
 
 • • • 
 
 • • • 
 
 • • • 
 
 • • • 
 
 
 , * * 
 
 . . . 
 
 
 
 
 
 
 
 ... 
 
 • • • 
 
 196 
 
 458 
 
 17 
 
 1814 
 
 • • • 
 
 6 
 
 13 
 
 • • • 
 
 
 3 
 
 7 
 
 
 
 
 
 ... 
 
 
 3 
 
 7 
 
 133 
 
 297 
 
 12 
 
 1815 
 
 • • • 
 
 7 
 
 15 
 
 • • • 
 
 
 1 
 
 2 
 
 
 
 
 
 . . . 
 
 
 1 
 
 2 
 
 192 
 
 411 
 
 14 
 
 1816 
 
 • • • 
 
 12 
 
 25 
 
 • • • 
 
 
 5 
 
 10 
 
 
 
 
 
 
 
 5 
 
 10 
 
 168 
 
 344 
 
 13 
 
 1817 
 
 • • • 
 
 10 
 
 20 
 
 • • • 
 
 
 2 
 
 4 
 
 
 
 
 
 ... 
 
 
 2 
 
 4 
 
 244 
 
 479 
 
 18 
 
 1818 
 
 • • • 
 
 31 
 
 58 
 
 • • • 
 
 
 7 
 
 13 
 
 
 
 
 
 
 
 7 
 
 13 
 
 353 
 
 664 
 
 21 
 
 1819 
 
 • • • 
 
 26 
 
 47 
 
 • • • 
 
 
 2 
 
 4 
 
 
 
 
 
 
 
 2 
 
 4 
 
 181 
 
 326 
 
 8 
 
 1820 
 
 • • • 
 
 64 
 
 111 
 
 • • • 
 
 
 5 
 
 9 
 
 
 • • • 
 
 
 
 
 
 5 
 
 9 
 
 288 
 
 498 
 
 19 
 
 1821 
 
 • • • 
 
 41 
 
 68 
 
 • • • 
 
 
 5 
 
 8 
 
 
 ... 
 
 
 
 • • . 
 
 
 5 
 
 8 
 
 302 
 
 501 
 
 16 
 
 1822 
 
 • • • 
 
 56 
 
 89 
 
 • • • 
 
 
 • • • 
 
 • • • 
 
 
 
 
 
 
 
 ... 
 
 • • • 
 
 362 
 
 576 
 
 16 
 
 1823 
 
 • • • 
 
 46 
 
 70 
 
 • • • 
 
 
 9 
 
 14 
 
 
 
 
 
 
 
 9 
 
 14 
 
 336 
 
 514 
 
 17 
 
 1824 
 
 • • • 
 
 13 
 
 19 
 
 • • • 
 
 
 2 
 
 3 
 
 
 • * * 
 
 
 
 
 
 2 
 
 3 
 
 134 
 
 197 
 
 10 
 
 1825 
 
 ■ • • 
 
 30 
 
 42 
 
 • • • 
 
 
 
 
 
 
 
 
 
 
 
 
 198 
 
 280 
 
 14 
 
 1826 
 
 • • • 
 
 47 
 
 64 
 
 • • • 
 
 
 
 
 
 
 
 
 
 
 
 
 203 
 
 276 
 
 11 
 
 1827 
 
 • • • 
 
 20 
 
 26 
 
 • • • 
 
 
 
 
 
 
 
 
 
 
 
 
 139 
 
 181 
 
 10 
 
 1828 
 
 • • • 
 
 20 
 
 25 
 
 • • • 
 
 
 
 
 
 
 
 
 
 
 
 
 173 
 
 218 
 
 11 
 
 1829 
 
 • • • 
 
 12 
 
 15 
 
 • • • 
 
 
 
 
 
 
 
 
 
 
 
 
 183 
 
 222 
 
 11 
 
 1830 
 
 • • • 
 
 21 
 
 25 
 
 • • • 
 
 
 
 
 
 
 
 
 
 
 
 
 268 
 
 313 
 
 14 
 
 1831 
 
 • • • 
 
 24 
 
 27 
 
 • • • 
 
 
 
 
 
 
 
 
 
 
 
 
 318 
 
 358 
 
 15 
 
 1832 
 
 • • • 
 
 58 
 
 63 
 
 853 
 
 926 
 
 
 
 
 
 
 
 
 
 
 
 1301 
 
 1412 
 
 38 
 
 1833 
 
 • • • 
 
 32 
 
 34 
 
 • • • 
 
 
 
 
 
 
 
 
 
 
 
 
 227 
 
 238 
 
 10 
 
 1834 
 
 • • • 
 
 39 
 
 39 
 
 71 
 
 72 
 
 
 
 
 
 
 
 
 
 
 
 407 
 
 412 
 
 16 
 
 1835 
 
 • • • 
 
 28 
 
 27 
 
 • • • 
 
 
 
 
 
 
 
 
 
 
 
 
 170 
 
 166 
 
 9 
 
 1836 
 
 • • • 
 
 25 
 
 24 
 
 • • • 
 
 
 
 
 
 
 
 
 
 
 
 
 257 
 
 243 
 
 9 
 
 1837 
 
 • • • 
 
 39 
 
 36 
 
 • • • 
 
 
 
 
 3 
 
 3 
 
 
 
 
 
 3 
 
 3 
 
 220 
 
 201 
 
 9 
 
 1838 
 
 • • • 
 
 25 
 
 22 
 
 • • • 
 
 
 
 
 5 
 
 4 
 
 
 
 
 
 5 
 
 4 
 
 270 
 
 238 
 
 11 
 
 1839 
 
 • • • 
 
 16 
 
 14 
 
 • • • 
 
 
 
 
 8 
 
 7 
 
 
 
 
 
 8 
 
 7 
 
 190 
 
 162 
 
 8 
 
 1840 
 
 • • • 
 
 27 
 
 22 
 
 • • • 
 
 
 
 
 10 
 
 8 
 
 
 
 
 
 10 
 
 8 
 
 201 
 
 166 
 
 10 
 
 1841 
 
 • • • 
 
 22 
 
 18 
 
 • « • 
 
 
 
 
 7 
 
 6 
 
 
 
 
 
 7 
 
 6 
 
 291 
 
 233 
 
 13 
 
 1842 
 
 • • • 
 
 25 
 
 19 
 
 • • • 
 
 
 
 
 12 
 
 9 
 
 
 
 * * * 
 
 
 12 
 
 9 
 
 325 
 
 252 
 
 13 
 
 1843 
 
 • • • 
 
 22 
 
 17 
 
 • • • 
 
 
 1 
 
 1 
 
 17 
 
 13 
 
 
 
 
 
 18 
 
 14 
 
 292 
 
 219 
 
 13 
 
 1844 
 
 • • • 
 
 13 
 
 9 
 
 • • • 
 
 
 2 
 
 1 
 
 22 
 
 16 
 
 
 
 
 
 24 
 
 17 
 
 231 
 
 168 
 
 9 
 
 1845 
 
 • • • 
 
 13 
 
 9 
 
 1 
 
 1 
 
 2 
 
 1 
 
 36 
 
 25 
 
 
 
 . • . 
 
 
 38 
 
 27 
 
 237 
 
 167 
 
 8 
 
 1846 
 
 • • • 
 
 7 
 
 5 
 
 
 
 
 
 25 
 
 17 
 
 
 
 * * * 
 
 
 25 
 
 17 
 
 276 
 
 189 
 
 9 
 
 1847 
 
 • • • 
 
 42 
 
 28 
 
 
 
 
 
 29 
 
 19 
 
 
 
 ... 
 
 
 29 
 
 19 
 
 460 
 
 306 
 
 13 
 
 1848 
 
 • • • 
 
 46 
 
 30 
 
 • • • 
 
 
 4 
 
 3 
 
 20 
 
 13 
 
 
 
 
 
 24 
 
 16 
 
 494 
 
 319 
 
 13 
 
 1849 
 
 • • • 
 
 148 
 
 93 
 
 • • • 
 
 
 4 
 
 3 
 
 21 
 
 13 
 
 
 
 
 
 25 
 
 16 
 
 721 
 
 453 
 
 17 
 
 1850 
 
 • • • 
 
 237 
 
 145 
 
 • • • 
 
 
 3 
 
 2 
 
 30 
 
 18 
 
 
 
 
 
 33 
 
 20 
 
 846 
 
 516 
 
 20 
 
 1851 
 
 • • • 
 
 161 
 
 95 
 
 • • • 
 
 
 
 
 19 
 
 11 
 
 
 
 71 
 
 42 
 
 90 
 
 53 
 
 732 
 
 434 
 
 18 
 
 1852 
 
 • • • 
 
 222 
 
 128 
 
 • • • 
 
 
 
 
 14 
 
 8 
 
 
 
 78 
 
 45 
 
 92 
 
 53 
 
 923 
 
 532 
 
 19 
 
 1853 
 
 • • • 
 
 242 
 
 136 
 
 • • • 
 
 
 
 
 18 
 
 10 
 
 
 
 101 
 
 57 
 
 119 
 
 67 
 
 864 
 
 485 
 
 18 
 
 1854 
 
 • • • 
 
 252 
 
 138 
 
 2 
 
 1 
 
 
 
 15 
 
 8 
 
 
 
 95 
 
 52 
 
 110 
 
 60 
 
 1207 
 
 659 
 
 23 
 
 1855 
 
 • • • 
 
 202 
 
 107 
 
 • • • 
 
 
 
 
 14 
 
 7 
 
 
 
 94 
 
 50 
 
 108 
 
 57 
 
 1059 
 
 563 
 
 21 
 
 1856 
 
 • • • 
 
 213 
 
 110 
 
 • • • 
 
 
 
 
 13 
 
 7 
 
 
 
 69 
 
 36 
 
 82 
 
 42 
 
 1188 
 
 614 
 
 23 
 
 1857 
 
 • • • 
 
 141 
 
 71 
 
 • • • 
 
 
 
 
 10 
 
 5 
 
 
 . . . 
 
 84 
 
 42 
 
 94 
 
 47 
 
 975 
 
 491 
 
 19 
 
 1858 
 
 • • • 
 
 137 
 
 67 
 
 • • • 
 
 
 
 
 7 
 
 3 
 
 
 
 100 
 
 49 
 
 107 
 
 53 
 
 951 
 
 467 
 
 18 
 
 1859 
 
 • • • 
 
 104 
 
 50 
 
 • • • 
 
 
 
 
 9 
 
 4 
 
 
 
 92 
 
 44 
 
 101 
 
 48 
 
 876 
 
 419 
 
 19 
 
 1860 
 
 • • • 
 
 59 
 
 28 
 
 • • • 
 
 
 
 
 8 
 
 4 
 
 
 
 101 
 
 47 
 
 109 
 
 51 
 
 828 
 
 386 
 
 17 
 
 1861 
 
 • • • 
 
 51 
 
 23 
 
 • • • 
 
 
 
 
 9 
 
 4 
 
 
 
 167 
 
 76 
 
 176 
 
 80 
 
 904 
 
 411 
 
 19 
 
 1862 
 
 m m m 
 
 43 
 
 19 
 
 
 
 
 
 11 
 
 5 
 
 
 
 202 
 
 90 
 
 213 
 
 94 
 
 819 
 
 363 
 
 16 
 
 1863 
 
 • • • 
 
 60 
 
 26 
 
 • • • 
 
 
 
 
 12 
 
 5 
 
 
 
 168 
 
 73 
 
 180 
 
 78 
 
 844 
 
 365 
 
 15 
 
 1864 
 
 • • • 
 
 73 
 
 31 
 
 • • • 
 
 
 
 
 5 
 
 2 
 
 
 
 200 
 
 84 
 
 205 
 
 87 
 
 911 
 
 385 
 
 16 
 
 1865 
 
 • • • 
 
 67 
 
 28 
 
 • • • 
 
 
 
 
 4 
 
 2 
 
 
 . . . 
 
 171 
 
 70 
 
 175 
 
 72 
 
 830 
 
 342 
 
 18 
 
 1866 
 
 . . . 
 
 67 
 
 27 
 
 62 
 
 25 
 
 
 
 5 
 
 2 
 
 ... 
 
 
 196 
 
 79 
 
 201 
 
 81 
 
 1032 
 
 415 
 
 18 
 
FEBRILE DISEASES 
 
 231 
 
 Table 19 .—Number of deaths and rate of death, per 100,000 living inhabitants, from diarrhoea, 
 
 dysentery, cholera, and typhoid fever, etc. —Continued. 
 
 D = death. It = rate. 
 
 Year. 
 
 Dysen¬ 
 
 tery. 
 
 Cholera. 
 
 Typhoid fever. 
 
 Grand 
 
 total. 
 
 Per 
 
 cent. 
 
 of 
 
 total 
 
 deaths 
 
 Nervous 
 
 fever. 
 
 Gastric 
 
 fever. 
 
 Typho- 
 
 malarial 
 
 fever. 
 
 Typhoid 
 
 fever. 
 
 Total. 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 1867 
 
 
 63 ! 
 
 25 
 
 
 
 
 
 11 
 
 4 
 
 
 • • • 
 
 235 
 
 92 
 
 246 
 
 97 
 
 1026 
 
 403 
 
 19 
 
 1868 
 
 • • • 
 
 85 
 
 33 
 
 
 
 
 
 9 
 
 3 
 
 
 • • • 
 
 167 
 
 64 
 
 176 
 
 68 
 
 1142 
 
 438 
 
 18 
 
 1869 
 
 • • • 
 
 83 
 
 31 
 
 
 
 
 .. t 
 
 14 
 
 5 
 
 
 • • • 
 
 210 
 
 79 
 
 224 
 
 84 
 
 1138 
 
 427 
 
 18 
 
 1870 
 
 
 65 
 
 24 
 
 
 
 
 
 25 
 
 9 
 
 
 • • • 
 
 265 
 
 97 
 
 290 
 
 106 
 
 1348 
 
 494 
 
 19 
 
 1871 
 
 • • • 
 
 83 
 
 30 
 
 
 
 
 
 9 
 
 3 
 
 
 • • • 
 
 200 
 
 72 
 
 209 
 
 75 
 
 1106 
 
 397 
 
 15 
 
 1872 
 
 
 71 
 
 25 
 
 
 
 
 
 15 
 
 5 
 
 
 • • • 
 
 229 
 
 80 
 
 244 
 
 86 
 
 1423 
 
 499 
 
 16 
 
 1873 
 
 ... 
 
 76 
 
 26 
 
 
 
 
 
 15 
 
 5 
 
 
 • • • 
 
 230 
 
 79 
 
 245 
 
 84 
 
 1356 
 
 465 
 
 18 
 
 1874 
 
 • • • 
 
 71 
 
 24 
 
 . . . 1 
 
 
 
 
 16 
 
 5 
 
 
 • • • 
 
 226 
 
 76 
 
 242 
 
 81 
 
 1575 
 
 528 
 
 21 
 
 1875 
 
 • • • 
 
 48 
 
 16 
 
 
 
 
 
 25 
 
 8 
 
 
 ... 
 
 187 
 
 61 
 
 212 
 
 70 
 
 1214 
 
 398 
 
 17 
 
 1876 
 
 
 57 
 
 18 
 
 
 
 
 
 
 
 6 
 
 2 
 
 177 
 
 57 
 
 183 
 
 59 
 
 1328 
 
 427 
 
 18 
 
 1877 
 
 
 49 
 
 15 
 
 4 
 
 1 
 
 ... 
 
 • • • 
 
 • • • 
 
 • • • 
 
 
 • • • 
 
 212 
 
 67 
 
 212 
 
 67 
 
 1264 
 
 397 
 
 16 
 
 1878 
 
 
 41 
 
 13 
 
 
 
 
 
 3 
 
 1 
 
 
 ... 
 
 177 
 
 55 
 
 180 
 
 55 
 
 856 
 
 264 
 
 13 
 
 1879 
 
 ... 
 
 60 
 
 18 
 
 2 
 
 1 
 
 • • • 
 
 • • • 
 
 6 
 
 2 
 
 17 
 
 5 
 
 167 
 
 50 
 
 190 
 
 57 
 
 1043 
 
 314 
 
 14 
 
 1880 
 
 • • • 
 
 57 
 
 17 
 
 
 
 
 
 5 
 
 1 
 
 31 
 
 9 
 
 197 
 
 58 
 
 233 
 
 69 
 
 1105 
 
 326 
 
 14 
 
 1881 
 
 • • • 
 
 56 
 
 16 
 
 
 
 
 
 5 
 
 1 
 
 50 
 
 14 
 
 197 
 
 57 
 
 252 
 
 73 
 
 1297 
 
 375 
 
 15 
 
 1882 
 
 • • • 
 
 62 
 
 18 
 
 
 
 
 
 1 
 
 • • • 
 
 44 
 
 12 
 
 165 
 
 47 
 
 210 
 
 60 
 
 1009 
 
 286 
 
 11 
 
 1883 
 
 • • • 
 
 52 
 
 14 
 
 
 
 
 
 3 
 
 1 
 
 48 
 
 13 
 
 126 
 
 35 
 
 177 
 
 49 
 
 1040 
 
 289 
 
 11 
 
 1884 
 
 ... 
 
 43 
 
 12 
 
 
 
 
 
 4 
 
 1 
 
 66 
 
 18 
 
 151 
 
 41 
 
 221 
 
 60 
 
 1176 
 
 320 
 
 14 
 
 1885 
 
 • • • 
 
 60 
 
 16 
 
 
 
 
 
 
 
 75 
 
 20 
 
 155 
 
 41 
 
 230 
 
 61 
 
 1157 
 
 309 
 
 14 
 
 1886 
 
 • • • 
 
 84 
 
 22 
 
 
 
 
 
 1 
 
 ... 
 
 58 
 
 15 
 
 150 
 
 39 
 
 209 
 
 55 
 
 1192 
 
 312 
 
 14 
 
 1887 
 
 • • • 
 
 138 
 
 35 
 
 
 
 
 
 
 
 55 
 
 14 
 
 156 
 
 40 
 
 211 
 
 54 
 
 1418 
 
 364 
 
 17 
 
 1888 
 
 • • • 
 
 167 
 
 40 
 
 
 
 
 
 
 
 41 
 
 10 
 
 161 
 
 38 
 
 202 
 
 48 
 
 1564 
 
 373 
 
 18 
 
 1889 
 
 • • • 
 
 156 
 
 37 
 
 
 
 
 
 
 
 33 
 
 8 
 
 191 
 
 45 
 
 224 
 
 52 
 
 1525 
 
 357 
 
 18 
 
 1890 
 
 • • • 
 
 212 
 
 49 
 
 
 
 
 
 
 
 54 
 
 12 
 
 247 
 
 57 
 
 301 
 
 69 
 
 1694 
 
 390 
 
 17 
 
 1891 
 
 • • • 
 
 18 
 
 4 
 
 
 
 
 
 
 
 39 
 
 9 
 
 150 
 
 34 
 
 189 
 
 43 
 
 1279 
 
 289 
 
 13 
 
 1892 
 
 • • • 
 
 109 
 
 24 
 
 
 
 
 
 
 
 33 
 
 7 
 
 193 
 
 43 
 
 226 
 
 50 
 
 1700 
 
 378 
 
 16 
 
 1893 
 
 • • • 
 
 62 
 
 14 
 
 
 
 
 
 
 
 31 
 
 7 
 
 224 
 
 49 
 
 255 
 
 56 
 
 1350 
 
 296 
 
 14 
 
 1894 
 
 • • • 
 
 72 
 
 16 
 
 
 
 
 
 
 
 35 
 
 8 
 
 222 
 
 48 
 
 257 
 
 55 
 
 1355 
 
 292 
 
 14 
 
 1895 
 
 ... 
 
 70 
 
 15 
 
 
 
 
 
 
 
 19 
 
 4 
 
 173 
 
 37 
 
 192 
 
 41 
 
 1361 
 
 289 
 
 13 
 
 1896 
 
 
 82 
 
 17 
 
 
 
 
 
 
 
 16 
 
 3 
 
 188 
 
 39 
 
 204 
 
 43 
 
 1253 
 
 262 
 
 13 
 
 1897 
 
 
 57 
 
 12 
 
 
 
 
 
 1 
 
 • • • 
 
 20 
 
 4 
 
 189 
 
 39 
 
 210 
 
 43 
 
 1247 
 
 257 
 
 13 
 
 1898 
 
 ... 
 
 82 
 
 17 
 
 
 
 
 
 
 
 12 
 
 2 
 
 189 
 
 38 
 
 201 
 
 41 
 
 1254 
 
 254 
 
 12 
 
 1899 
 
 ... 
 
 57 
 
 11 
 
 
 
 
 
 
 
 
 
 153 
 
 31 
 
 153 
 
 31 
 
 1094 
 
 219 
 
 11 
 
 1900 
 
 
 77 
 
 15 
 
 
 
 
 
 
 
 
 
 189 
 
 37 
 
 189 
 
 37 
 
 1225 
 
 242 
 
 11 
 
 1901 
 
 ... 
 
 49 
 
 10 
 
 
 
 
 
 
 
 
 
 141 
 
 27 
 
 141 
 
 27 
 
 1011 
 
 197 
 
 10 
 
 1902 
 
 ... 
 
 78 
 
 15 
 
 
 
 
 
 
 
 
 
 220 
 
 42 
 
 220 
 
 42 
 
 1091 
 
 210 
 
 11 
 
 1903 
 
 
 40 
 
 8 
 
 
 
 
 
 
 
 
 
 189 
 
 36 
 
 189 
 
 36 
 
 855 
 
 162 
 
 8 
 
 1904 
 
 ... 
 
 54 
 
 10 
 
 
 
 
 
 
 
 
 
 199 
 
 37 
 
 199 
 
 37 
 
 1002 
 
 188 
 
 9 
 
 1905 
 
 
 44 
 
 8 
 
 
 
 
 
 
 
 
 
 197 
 
 36 
 
 197 
 
 36 
 
 1082 
 
 200 
 
 10 
 
 1906 
 
 
 37 
 
 7 
 
 
 
 
 
 
 
 
 
 183 
 
 33 
 
 183 
 
 33 
 
 933 
 
 171 
 
 9 
 
 1907 
 
 
 48 
 
 9 
 
 
 
 
 
 
 
 
 
 230 
 
 42 
 
 230 
 
 42 
 
 1158 
 
 209 
 
 10 
 
 1908 
 
 ... 
 
 35 
 
 6 
 
 
 
 
 
 
 
 
 
 180 
 
 32 
 
 180 
 
 32 
 
 930 
 
 166 
 
 9 
 
 1909 
 
 
 33 
 
 6 
 
 
 
 
 
 
 
 
 
 136 
 
 24 
 
 136 
 
 24 
 
 855 
 
 151 
 
 8 
 
 1910 
 
 • • • 
 
 31 
 
 5 
 
 
 
 
 
 
 
 
 
 235 
 
 41 
 
 235 
 
 41 
 
 983 
 
 172 
 
 9 
 
 1911 
 
 • • • 
 
 25 
 
 4 
 
 
 
 
 
 
 
 
 
 154 
 
 27 
 
 154 
 
 27 
 
 833 
 
 144 
 
 8 
 
 1912 
 
 • • • 
 
 17 
 
 3 
 
 
 
 
 
 
 
 
 
 136 
 
 23 
 
 136 
 
 23 
 
 745 
 
 128 
 
 7 
 
 1913 
 
 • • • 
 
 21 
 
 4 
 
 
 
 
 
 
 
 
 
 135 
 
 23 
 
 135 
 
 23 
 
 799 
 
 135 
 
 8 
 
 1914 
 
 • • • 
 
 10 
 
 2 
 
 
 
 
 
 
 
 
 
 130 
 
 22 
 
 130 
 
 22 
 
 782 
 
 131 
 
 7 
 
 1915 
 
 
 12 
 
 2 
 
 
 
 
 
 
 
 
 
 128 
 
 21 
 
 128 
 
 21 
 
 711 
 
 118 
 
 7 
 
 1916 
 
 
 7 
 
 1 
 
 
 
 
 
 
 
 
 
 107 
 
 18 
 
 107 
 
 18 
 
 778 
 
 128 
 
 7 
 
 1917 
 
 • • • 
 
 5 
 
 1 
 
 
 
 
 
 
 
 
 
 92 
 
 15 
 
 92 
 
 15 
 
 833 
 
 136 
 
 7 
 
 1918 
 
 • • • 
 
 5 
 
 1 
 
 
 
 
 
 
 
 
 
 73 
 
 12 
 
 73 
 
 12 
 
 1016 
 
 164 
 
 6 
 
 1919 
 
 • • • 
 
 3 
 
 
 
 
 
 
 
 
 
 
 60 
 
 8 
 
 60 
 
 8 
 
 813 
 
 113 
 
 7 
 
 1920 
 
 • • • 
 
 22 
 
 3 
 
 
 
 
 
 
 
 
 
 35 
 
 5 
 
 35 
 
 5 
 
 825 
 
 112 
 
 7 
 
232 PUBLIC HEALTH ADMINISTRATION - , ETC., IN BALTIMORE 
 
 of blood and pus, it has been commonly assumed that the affection is a single 
 and distinct entity, and the work of pathological anatomists and of bacteri¬ 
 ologists, including that of Booker (54), in 1895, who found streptococci in 
 the intestinal lesions of a group of cases, and of Duval and Bassett (55), in 
 1902, who cultivated varieties of B. dysenteric from the stools of certain Balti¬ 
 more cases, did not seriously upset this prevailing conception. 
 
 The recent demonstration by Professor John Howland (personal communi¬ 
 cation) and his coworkers that B. dysenteric , in relation to infantile diarrhoeas 
 in Baltimore, is confined strictly to cases with bloody stools and that this form 
 of bowel affection occurs from time to time in epidemic outbreaks in widely 
 separated areas in Baltimore and may spread among children with other affec- 
 
 Graph 5 (from table 19). Animal crude mortality rates from diarrhoea, from 
 
 1812 to 1920, inclusive. 
 
 tions in a well administered hospital when cases are admitted to the wards, is 
 of far-reaching importance. Thus, for Baltimore, it appears to be conclusively 
 established that this rubric, cholera infantum, consists of at least two separate 
 elements, the dysentery and the non-dysentery. The dysentery type of infantile 
 enteritis is often particularly fatal, but no data exist for comparing its lethal 
 powers with the group or groups of other types and causation. That dysentery 
 was an important cause of death among infants is shown by the high death- 
 rate under 1 year of age from this disease in 1850. William T. Howard, sr. (86), 
 was struck with the close relationship between cholera infantum and dysentery, 
 and in his lectures written about 1870 stated that when the infant in a family 
 became ill with cholera infantum, older children in the same household were 
 often attacked by typical dysentery. 
 
FEBRILE DISEASES 
 
 233 
 
 It will be noted from table 19 that high death-rates from cholera infantum 
 have often, but by no means invariably, synchronized in time with high rates 
 for dysentery, and there would appear to be a rough sort of correlation in the 
 simultaneous fall in these two rates particularly during the last few years. 
 However, since knowledge concerning the proportional distribution of the 
 deaths ascribed to dysentery among the several varieties of this disease as 
 clinically and anatomically defined is entirely lacking, any attempt at close 
 comparison between its course and that of cholera infantum is manifestly 
 unwarranted. Whether the non-dysentery moiety of infantile enteritis is due 
 to the same indefinite congeries of causes, to which the diarrhoeas of older 
 children and adults is ascribed, is, of course, unknown. It must be clearly 
 recognized that, as here used, cholera infantum is from neither the etiological 
 nor the anatomical standpoints a specific disease entity, but that it embraces 
 deaths which under a proper causal classification would be ascribed to dysentery, 
 and in other ways it is not strictly comparable with diarrhoea (rubric 105), 
 which, in theory at least, avowedly excludes all dysenteries. 
 
 Assuming for the purpose of the present study that the figures recorded for 
 deaths from cholera infantum and teething are correct, and that these headings 
 taken together represent, from 1821 to 1898, the later rubric 104 of the 
 international classification, the course of its force of mortality may be followed 
 for 100 years. Such rates are far from specific as regards age of those exposed 
 to risk and much less so than those calculated for dysentery and for diarrhoea. 
 For according to definition, in calculating the rates for the latter rubric, the 
 divisor includes erroneously the relatively small age-group under the second 
 year of age and from the dividend the deaths from these affections within this 
 age-group are excluded, while in the rates for cholera infantum the divisor 
 includes the comparatively great moiety of population above the second year 
 used upon a dividend represented by the number of deaths within this very 
 restricted age group. On this basis, for direct comparison, the rates for cholera 
 infantum would have to be multiplied something over 20 times. And again, 
 strict comparison of the rates for this rubric for the earlier years with those of 
 the later years is unwarranted because of changes in the age-groupings of the 
 population. It is evident that the rate for cholera infantum would be materially 
 affected by changes in the birth-rate, and by the rise and fall in the death rates 
 from such affections as measles, scarlet fever, whooping-cough, and diphtheria. 
 
 Even while bearing constantly in mind these various explanations and 
 reservations made necessary by the character of the data available (from study 
 of table 19 and graph 5), it is abundantly evident that the annual rates for 
 cholera infantum, as calculated, are not only very high and show frequently 
 substantial variations from year to year, but exhibit several major and minor 
 waves often extending over periods embracing a considerable number of years. 
 In other words, the force of mortality, always considerable, has often varied 
 widely from year to year and from period to period in the population’s history. 
 Beginning some time before 1821 and ending in 1823, there was a wave of 
 appalling mortality. The rate for 1822 (439 per 100,000 total population, but 
 something like 10,000 per 100,000, or 1 in every 10 exposed to risk, i. e., under 
 the second year of age) was higher than any since recorded. A rate even higher 
 probably obtained in 1818. The abrupt fall in 1824, with the slight rise during 
 the next 2 years, was followed by the termination of this wave in 1827 with 
 
234 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 a rate of 115. A second wave starting in 1828 reached its peak in 1832 (the 
 year of the great cholera epidemic) with a rate of 378; after a substantial fall 
 the next year and a minor rise in 1834 (the second cholera year), it fell to a 
 low point (109) in 1835. This sharply cut wave, attended with correspondingly 
 higher rates for diarrhoea, and with a rate higher than usual for dysentery in 
 the peak year (1832), covered a period of 7 years. The next 10 years was a 
 period of relatively low rates, with considerable annual fluctuation, and in 1845 
 the remarkably low rate of 93 was attained. During this 10-year period the 
 rates for dysentery were low and on the whole declining, and those for diarrhoea, 
 which fell during the first half, rose correspondingly in the second half. 
 
 The year 1846 signaled the beginning of a third wave of mortality, which, 
 mounting gradually and broken now and again by slight recessions, reached 
 its peak in 1856 with a rate of .400, and descending gradually, subsided in 1865 
 with a rate of 164. During the first half of this 20-year wave the rates for both 
 diarrhoea and dysentery were high, and indeed reached their highest recorded 
 level, the latter in 1850 and the former in 1854 (a cholera year, when, however, 
 practically all the deaths from cholera must have been credited to diarrhoea 
 and cholera infantum). During the last half of the period the rates for 
 dysentery subsided sharply and markedly and those for diarrhoea first fell and 
 later rose. 
 
 It will he noted that cholera infantum achieved its highest rate 2 years 
 later than diarrhoea and 6 years later than dysentery. In a fourth great wave, 
 extending from 1866 to 1878, the rise to the crest, reached in 1874 (with a 
 rate of 352), was gradual and broken frequently by larger and smaller reces¬ 
 sions, while the descent was marked by an almost continuous fall to the com¬ 
 paratively low rate of 130 in 1878. During this whole period the rates for 
 dysentery were low, and during the descent of the wave for cholera infantum 
 the curves for the two rubrics followed the same general course. The rates for 
 diarrhoea, on the other hand, continued until in 1871 the very definite ascent 
 begun in 1861, but fell decidedly during the peak of the wave for cholera 
 infantum, only to ascend again during the years of the latter’s decline. The low 
 point attained at the end of the fourth wave was lower than that of the third 
 but considerably higher than those of the first and second waves. From 1879 
 to 1892 the course of the curve for cholera infantum was fairly even, with 
 rates varying between 153 and 195. The rates for diarrhoea ascended gradually 
 to the highest point attained in years, and a sharp rise in the rates for dysentery 
 (1886-1890) was apparently without influence upon those of cholera infantum. 
 Between 1899 and 1907, in the face of a sharp drop in the rates for diarrhoea 
 and the continued descent for those for dysentery, the rates for cholera infan¬ 
 tum completely reversed their course. Then until 1915, in the face of low and 
 fairly well stabilized rates for diarrhoea and the descent of those for dysentery 
 to nearly the vanishing-point, the rates for cholera infantum fell, with some 
 fluctuations, to 80, the lowest point recorded in the city’s history. A sharp 
 rise in cholera infantum during the next 3 years to a rate of 129 and a decline 
 in 1919 to 85 were associated with corresponding changes in the rates for 
 diarrhoea. Finally, the slight rise in cholera infantum in 1920 synchronized 
 with a similar change in dysentery, an association possibly significant. 
 
 Turning now to the consideration of the annual rates averaged for 5- and 
 10-year periods, from 1821 to 1920, inclusive (table 20, graph 6), and making 
 
FEBRILE DISEASES 
 
 Oor: 
 
 4J(J tJ 
 
 Table 20 .—Average rate of death by 5- and 10-year 'periods from acute inflammatory in¬ 
 fections of intestinal tract, from 1812 to 1920, inclusive. 
 
 Period. 
 
 Diarrhoea 
 under2vears 
 of age. 
 
 Diarrhoea. 
 
 Diarrhoea 
 over 2 years 
 of age. 
 
 Total. 
 
 Dysentery. 
 
 Cholera. 
 
 Typhoid 
 
 fever. 
 
 Total. 
 
 By 5-year 
 periods. 
 
 By 10-year 
 periods. 
 
 By 5-year 
 periods. 
 
 By 10-year 
 periods. 
 
 By 5-year 
 periods. 
 
 k 
 
 r “l <u 
 
 cq 
 
 By 5-year 
 
 periods. 
 
 By 10-year 
 
 periods. 
 
 By 5-year 
 
 periods. 
 
 By 10-year 
 
 periods. 
 
 By 6-year 
 
 periods. 
 
 L* 
 
 cd • 
 rr co 
 
 ?*o 
 
 s*S 
 
 « 
 
 By 5-year 
 
 periods. 
 
 By 10-year 
 
 periods. 
 
 1812 
 
 to 
 
 15... 
 
 12 
 
 % • • • 
 
 383 
 
 
 395 
 
 • • • • 
 
 7 
 
 • • • » 
 
 
 
 3 
 
 • • • * 
 
 406 
 
 • • • • 
 
 1816 
 
 to 
 
 20... 
 
 27 
 
 20 
 
 375 
 
 379 
 
 402 
 
 399 
 
 52 
 
 32 
 
 
 
 8 
 
 6 
 
 462 
 
 437 
 
 1821 
 
 to 
 
 25... 
 
 295 
 
 % • • • 
 
 55 
 
 • • • • 
 
 350 
 
 • • • • 
 
 58 
 
 • • • • 
 
 
 
 5 
 
 • • • • 
 
 413 
 
 • • • • 
 
 1826 
 
 to 
 
 30... 
 
 168 
 
 232 
 
 43 
 
 50 
 
 211 
 
 282 
 
 31 
 
 44 
 
 
 
 • • • • 
 
 3 
 
 242 
 
 328 
 
 1831 
 
 to 
 
 35... 
 
 237 
 
 % • • • 
 
 43 
 
 t i « • 
 
 280 
 
 • • • • 
 
 38 
 
 • • • • 
 
 200 
 
 
 * • • • 
 
 • • • • 
 
 517 
 
 • • • • 
 
 1836 
 
 to 
 
 40... 
 
 153 
 
 195 
 
 21 
 
 32 
 
 174 
 
 227 
 
 23 
 
 31 
 
 
 100 
 
 4 
 
 2 
 
 202 
 
 360 
 
 1841 
 
 to 
 
 45... 
 
 139 
 
 
 40 
 
 • • • • 
 
 179 
 
 • • • • 
 
 14 
 
 • • • • 
 
 
 
 15 
 
 • • • • 
 
 208 
 
 • • • • 
 
 1846 
 
 to 
 
 50... 
 
 214 
 
 176 
 
 65 
 
 53 
 
 279 
 
 229 
 
 60 
 
 37 
 
 
 
 18 
 
 16 
 
 357 
 
 282 
 
 1851 
 
 to 
 
 55... 
 
 256 
 
 * • • • 
 
 100 
 
 • • • • 
 
 356 
 
 • • • • 
 
 121 
 
 • • • • 
 
 
 
 58 
 
 • • • • 
 
 534 
 
 • • • • 
 
 1856 
 
 to 
 
 60... 
 
 300 
 
 278 
 
 62 
 
 81 
 
 362 
 
 359 
 
 65 
 
 93 
 
 
 
 48 
 
 53 
 
 475 
 
 505 
 
 1861 
 
 to 
 
 65... 
 
 197 
 
 • • • • 
 
 68 
 
 « • • • 
 
 265 
 
 • • • • 
 
 25 
 
 • • • • 
 
 
 
 82 
 
 • • • • 
 
 373 
 
 • • • • 
 
 1866 
 
 to 
 
 70... 
 
 228 
 
 213 
 
 88 
 
 78 
 
 316 
 
 291 
 
 28 
 
 27 
 
 5 
 
 3 
 
 87 
 
 85 
 
 436 
 
 404 
 
 1871 
 
 to 
 
 75... 
 
 282 
 
 * • • • 
 
 72 
 
 » • « • 
 
 354 
 
 * • • • 
 
 24 
 
 • • • • 
 
 
 
 79 
 
 • • • • 
 
 457 
 
 • • • • 
 
 1876 
 
 to 
 
 80... 
 
 198 
 
 240 
 
 70 
 
 71 
 
 268 
 
 311 
 
 16 
 
 20 
 
 
 
 61 
 
 70 
 
 346 
 
 402 
 
 1881 
 
 to 
 
 85... 
 
 162 
 
 % • • • 
 
 78 
 
 » • • • 
 
 240 
 
 » • • • 
 
 15 
 
 « • • • 
 
 
 
 61 
 
 % • • • 
 
 316 
 
 • • • • 
 
 1886 
 
 to 
 
 90... 
 
 162 
 
 162 
 
 105 
 
 91 
 
 267 
 
 253 
 
 37 
 
 26 
 
 
 
 56 
 
 58 
 
 359 
 
 338 
 
 1891 
 
 to 
 
 95... 
 
 136 
 
 » • • • 
 
 109 
 
 • • • • 
 
 245 
 
 * • • • 
 
 14 
 
 » • t • 
 
 
 
 49 
 
 • • • • 
 
 309 
 
 • • • • 
 
 1896 
 
 to 
 
 1900. 
 
 120 
 
 128 
 
 74 
 
 92 
 
 194 
 
 220 
 
 14 
 
 14 
 
 
 
 39 
 
 44 
 
 247 
 
 278 
 
 1901 
 
 to 
 
 05... 
 
 129 
 
 « i • • 
 
 17 
 
 • • • • 
 
 146 
 
 • • • • 
 
 10 
 
 
 
 
 36 
 
 » • • • 
 
 191 
 
 • • • • 
 
 1906 
 
 to 
 
 10... 
 
 112 
 
 120 
 
 21 
 
 19 
 
 133 
 
 139 
 
 7 
 
 8 
 
 
 
 34 
 
 35 
 
 174 
 
 182 
 
 1911 
 
 to 
 
 15... 
 
 90 
 
 « • • • 
 
 15 
 
 • • • • 
 
 105 
 
 • • • • 
 
 3 
 
 « • • • 
 
 
 
 23 
 
 % • • • 
 
 131 
 
 • • • • 
 
 1916 
 
 to 
 
 20... 
 
 101 
 
 95 
 
 17 
 
 16 
 
 118 
 
 111 
 
 1 
 
 2 
 
 
 
 12 
 
 17 
 
 131 
 
 131 
 
 Graph 6 (from table 20). Crude mortality rates from diarrhoea, averaged 
 by 5-year periods, from 1812 to 1920, inclusive. 
 
 16 
 
236 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 the necessary allowances for this arbitrary division in the time relationships, 
 a very clear-cut picture is obtained of the lethal course of cholera infantum 
 during 100 years. The 5-year averaged rates fell from the high level of 295 in 
 1821-1825 to 168 in 1826-1830. The peak of a second wave stands out in 
 1831-1835 with a rate of 237, which was followed by a gradual decline to a 
 rate of 139 in 1841-1845. A third wave, with a gradual rise in rates during 15 
 years to a peak-rate of 300 in 1856-1860, had receded to a rate of 197 in 1861- 
 1865, when its further fall was arrested by the beginning of a fourth wave. 
 The latter reaching its crest in 1871-1875 with a rate of 282, during the next 
 10 years fell to 162, a level maintained for the 5 years ending in 1890. From 
 this point, except for a slight rise in 1901-1905, there was an uninterrupted 
 decline until 1911-1915, when the averaged rates stood at 90, the lowest level 
 reached. During the last 5 years the rate reacted slightly to 101. 
 
 With the annual rates averaged for 10-year periods beginning in 1821, the 
 second wave above noted is smoothed out and by 1846-1850 the rate had fallen 
 from the initial figure 232 in 1826-1830 to 176. For the 10 years ending in 
 1860 the high rate of 278 was attained. A drop in these rates to 213 in 1866- 
 1870 was followed by a rise of 240 in 1876-1880. During the succeeding 40 
 years the rates fell steadily and almost uniformly to 95 in 1911-1920. 
 
 The period ending in 1880 marked the turning point of the curves for both 
 the 5- and 10-year averaged rates. When these pictures are viewed with a 
 critical eye, certain points stand out with striking distinctness. Previous to 
 the beginning of the present records there had occurred a long wave of high 
 mortality marked by minor fluctuations and extending to some date prior to 
 1821, which, for some reason or reasons not entirely clear, began to recede 
 between 1826-1830 and 1836-1840 and reached its ebb about 1841-1845. After 
 1845 there began a second long wave (broken by two sharp crests) whose 
 recession began about 1876-1880, and by 1891-1895 the averaged annual rate 
 stood at about the same level of that of 1841-1845. These intermediate 50 
 years witnessed sensational changes in the lethal force of this affection. The 
 action of the cause or causes concerned began suddenly and attained maximum 
 intensity between 1841-1845 and 1856-1860. Operating with somewhat less¬ 
 ened intensity during the next 5 or 10 years, they exhibited a final outburst of 
 force between 1870 and 1880, and, losing power steadily since the latter date, 
 they have shown no evidence of a capacity to regain their former vigor. What¬ 
 ever the character of these causes, it is very clear that, after losing to a con¬ 
 siderable degree about 1841-1845 the force which they had exerted during a 
 long series of years, they regained it with renewed strength after this date and, 
 after holding the field with pow'er scarcely abated for about 30 years, they sub¬ 
 sided very decidedly after 1880. 
 
 Since over such long stretches of time the data on which these crude rates 
 are based have been subject to such a variety of influences, concerned particu¬ 
 larly with changes in the birth-rate and in the death-rates for many diseases 
 and resulting marked differences in the age distributions of the population for 
 which it is impossible to make accurate allowances, it is important to seek rates 
 specific for age at least at different periods. The results for the 8 census years 
 from 1850 to 1920, inclusive, are presented in table 21. Except in 1900 and 
 1910, the population figures used are only approximations; hence the rates 
 
FEBRILE DISEASES 
 
 237 
 
 derived may be regarded as only relatively accurate. Assuming that they are 
 comparable within a reasonably small degree of error, it appears that the rate 
 rose from about 3,300 in 1850 to about 4,200 in 1860 and, remaining unchanged 
 in 1870, fell by 1890 to approximately the level of 1850. Between 1890 and 
 1900 it rose from about 3,400 to about 3,700, and falling to 2,700 in 1910, 
 reached the comparatively low level of 2,200 by 1920. 
 
 From table 22 the influence of sex and color upon the death-rate from cholera 
 infantum is shown for both the first and the second year of life, for the 6 years 
 1910 to 1915. Under the first year of age the rates for males, both white and 
 colored, were higher than those for females in every year but one; in the second 
 year of age the rates for males were higher than those for females, in whites in 
 4 and in colored in 2 out of the 6 years. For both years taken together the 
 
 Table 21.— Rate of death, per 100,000 living inhabitants under two years 
 of age, from diarrhoea under two years of age, calculated on estimated 
 populations under two years, except in 1900 and 1910 when census 
 count was obtainable. 
 
 Year. 
 
 Population 
 under 2 years. 
 
 Diarrhoea 
 under 2 years 
 of age. 
 
 Remarks. 
 
 Deaths. 
 
 Rate. 
 
 1850 
 
 12472 
 
 407 
 
 3263 
 
 The number of deaths for each 
 
 1860 
 
 12742 
 
 544 
 
 4269 
 
 designated year represents an 
 
 1870 
 
 14544 
 
 617 
 
 4242 
 
 average of the deaths for that 
 
 1880 
 
 16227 
 
 618 
 
 3808 
 
 year and for those next preced- 
 
 1890 
 
 18762 
 
 646 
 
 3443 
 
 ing and following, except for 
 
 1900 
 
 20220 
 
 759 
 
 3754 
 
 1920, when the number of deaths 
 
 1910 
 
 19851 
 
 543 
 
 2735 
 
 represents an average of the 
 
 1920 
 
 28902 
 
 640 
 
 2214 
 
 deaths for 1919 and 1920. 
 
 rates were higher in males than in females in whites in 4 and in colored in 5 
 out of the 6 years. The rates for the first and second years of age averaged 
 for the 6 years were for white males 2,660, white females 2,355, colored males 
 5,197, colored females 4,416. When these are compared it is seen that the rates 
 were 13 per cent higher in white males than in white females, 18 per cent higher 
 in colored males than in colored females, 95 per cent higher in colored males 
 than in white males, and 88 per cent higher in colored females than in white 
 females. The advantage lay distinctly with the female over the male and with 
 the white over the negro. 
 
 Probably always, but certainly since the distribution of deaths by months has 
 been recorded (since 1860), the highest monthly mortality rates have fallen in 
 the warm months. July and August commonly show the highest monthly rates. 
 The monthly rates for sex, age, and color are shown in a typical year in 
 table 23. According to Frick’s calculations, in 1850 the proportion of deaths 
 from cholera infantum to the 10.000 inhabitants was 22.5 for whites and 10.6 
 for blacks. Of the whole number of deaths in both races, 48 per cent were in 
 males and 52 per cent in females. 
 
 In 1917, a typical recent year, of the deaths from all causes in children in 
 the first and second years of life the percentages due to cholera infantum in the 
 
238 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 former age-group were for whites 31.5, for negroes 26, for total 30.3, and in 
 the latter age-group, for w T hites 32, for negroes 19.2, and for total 27.3. 
 
 From the earliest days in the annual reports of the health department atten¬ 
 tion has been frequently directed to the enormous mortality from cholera infan- 
 
 Table 22 .—Number of deaths and, the rate of death, per 100,000 living inhabitants un¬ 
 der 2 years of age, from diarrhoea in children under 2, according to age, color, and 
 sex, from 1910 to 1915, inclusive * 
 
 D = death. R = rate. 
 TOTAL. 
 
 
 White. 
 
 Colored. 
 
 Year. 
 
 Male. 
 
 Female. 
 
 Male. 
 
 Female. 
 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 1910 ... 
 
 242 
 
 2727 
 
 204 
 
 2399 
 
 104 
 
 8374 
 
 70 
 
 5677 
 
 1911 ... 
 
 221 
 
 2467 
 
 235 
 
 2736 
 
 65 
 
 5179 
 
 62 
 
 5012 
 
 1912 ... 
 
 197 
 
 2178 
 
 193 
 
 2225 
 
 55 
 
 4338 
 
 65 
 
 5237 
 
 1913 ... 
 
 264 
 
 2890 
 
 208 
 
 2374 
 
 63 
 
 4918 
 
 54 
 
 4337 
 
 1914 ... 
 
 246 
 
 2667 
 
 220 
 
 2487 
 
 60 
 
 4637 
 
 45 
 
 3603 
 
 1915 ... 
 
 221 
 
 2373 
 
 171 
 
 1914 
 
 49 
 
 3749 
 
 33 
 
 2634 
 
 UNDER ONE YEAR. 
 
 1910 ... 
 
 208 
 
 4634 
 
 165 
 
 3748 
 
 92 
 
 13431 
 
 62 
 
 9351 
 
 1911 ... 
 
 183 
 
 4037 
 
 205 
 
 4611 
 
 58 
 
 8382 
 
 54 
 
 8120 
 
 1912 ... 
 
 169 
 
 3692 
 
 156 
 
 3474 
 
 51 
 
 7296 
 
 58 
 
 8696 
 
 1913 ... 
 
 219 
 
 4739 
 
 183 
 
 4035 
 
 59 
 
 8357 
 
 45 
 
 6726 
 
 1914 ... 
 
 207 
 
 4436 
 
 185 
 
 4039 
 
 54 
 
 7574 
 
 40 
 
 5961 
 
 1915 ... 
 
 184 
 
 3906 
 
 137 
 
 2962 
 
 44 
 
 6111 
 
 27 
 
 4012 
 
 BETWEEN ONE AND TWO YEARS. 
 
 1910 ... 
 
 34 
 
 776 
 
 39 
 
 951 
 
 12 
 
 2154 
 
 8 
 
 1404 
 
 1911 ... 
 
 38 
 
 858 
 
 30 
 
 724 
 
 7 
 
 1243 
 
 8 
 
 1399 
 
 1912 ... 
 
 28 
 
 626 
 
 37 
 
 885 
 
 4 
 
 703 
 
 7 
 
 1220 
 
 1913 ... 
 
 45 
 
 997 
 
 25 
 
 592 
 
 4 
 
 696 
 
 9 
 
 1563 
 
 1914 ... 
 
 39 
 
 856 
 
 35 
 
 820 
 
 6 
 
 1033 
 
 5 
 
 865 
 
 1915 ... 
 
 37 
 
 804 
 
 34 
 
 789 
 
 5 
 
 852 
 
 6 
 
 1034 
 
 * The totals of these figures, which were obtained from special tables in the annual 
 reports, do not correspond with those given in the tables of deaths from all causes, but 
 their proportionate distribution by color and sex may be regarded as relatively accurate. 
 
 The population figures used in computing rates for 1910 are those furnished by the 
 Bureau of the Census. Owing to peculiar population changes in connection with the World 
 War, the population figures used for 1911 to 1915, inclusive, were derived by exterpolation 
 from the figures for 1910 rather than by interpolation from the figures for 1920. 
 
 turn, but except for recommending parks and the planting of shade trees, no rec¬ 
 ommendations were made until very recent years. While ever ready to cooperate 
 with private agencies in furnishing statistical information, the health depart¬ 
 ment has always confined its activities to general measures. The mortality of 
 babies from cholera infantum in the larger foundling asylums was particularly 
 heavy until the last few years. All effective efforts of a specific character to 
 
FEBRILE DISEASES 
 
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240 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 control the mortality from this disease have been executed by physicians and 
 by certain private organizations. The medical profession has always insisted 
 upon the importance of breast-feeding over the second summer if possible, and 
 when this was impracticable upon the use of the best cow’s milk procurable and 
 properly modified. For both prevention and cure, removal of babies to the 
 country was standard advice to mothers who could afford it. As early as 1870, 
 William T. Howard, sr. (52), taught that babies weaned after April 1 rarely 
 if ever escaped cholera infantum during the succeeding summer if kept in the 
 city. While the public dispensaries and those connected with various hospitals 
 had special services for children’s diseases, the first organized pediatric clinic 
 to undertake in a truly scientific manner the prevention and cure of infantile 
 diarrhoea was that established in 1889 under the charge of Dr. William D. 
 Booker, at the dispensary of the Johns Hopkins Hospital. Work on similar 
 lines was soon undertaken at the Robert Garrett Hospital under the direction 
 of Dr. Walter B. Platt, and at the Nursery and Children’s Hospital by Drs. 
 Friedenwald and Buhrah. By 1900 the treatment of this disease had greatly 
 improved at all the dispensaries with children’s clinics. Booker was responsible 
 for introducing the practice of pasteurization of milk for babies about 1892, 
 the modification of cow’s milk on scientific principles for infant feeding about 
 1895, and persuading Mr. Samuel M. Shoemaker to establish a Walker-Gordon 
 milk laboratory to supply pure milk, both modified and whole in 1900. 
 
 The Thomas Wilson Sanatorium, the first endowed philanthropic institution 
 in the city to contribute in a large way to the decrease in the death-rate from 
 cholera infantum, opened its summer home in the country for babies ill with 
 this disease in 1884. This institution has ever since favorably affected the 
 official death-rate from cholera infantum, not only by preventing deaths among 
 its patients, but by the fact that many children died there whose deaths would 
 otherwise have occurred in the city. In addition to its other beneficent services 
 and hardly of less importance, it afforded Booker, as director from 1884 to 
 1898, the necessary opportunity to pursue the studies and to gain the experience 
 on which his qualifications for leadership were based. On Booker’s pioneer 
 work all real advances in the control of cholera infantum in Baltimore have 
 been based. In 1904 the sanatorium established four milk stations in the city 
 to provide good milk and nursing care for the babies. Milk modified in a 
 number of simple mixtures by the Walker-Gordon laboratory was dispensed. 
 By 1912 the Babies Milk Fund Association, which was organized in 1904 to 
 operate these milk stations, substituted for the distribution of modified milk 
 the practice of teaching mothers to modify milk in their homes. In addition a 
 number of welfare clinics were established for the oversight of babies and the 
 instruction of mothers in their feeding and general care. By 1918, 22 weekly 
 clinics were held, and 22 nurses were employed. This year the medical direc¬ 
 tors, Dr. J. H. Mason Knox, jr. and Dr. Govan F. Powers, reported that of the 
 5,795 children under 3 years of age that were under observation at the clinics, 
 only 36 or 0.6 per cent died of cholera infantum, and of the 4,700 children who 
 received nursing supervision alone only 78 or 1.6 per cent died of this disease, 
 while the rate for the remaining children of this age in the city was something 
 less than 3 per cent. The disposition of mothers of certain race stocks to nurse 
 their babies must have exerted a considerable influence upon cholera infantum; 
 
FEBRILE DISEASES 
 
 241 
 
 while for the earlier years there is no definite information on this subject, 
 inquiry has disclosed that mothers among some races of more recent immigra¬ 
 tion, i. e., Bohemians, Italians, Poles, and Polish Jews especially, with few 
 exceptions nurse their babies faithfully and often over the second summer. 
 
 While cholera infantum or “ summer complaint ” of young children has 
 been—though in the light of recent knowledge, probably erroneously—con¬ 
 sidered from time immemorial to be a single and specific disease entity, no 
 such claim has been consistently made for the heterogeneous collection of acute 
 intestinal affections so variously named as cholera morbus, cramp colic, and 
 inflammation of the bowels, and finally classed together on the strength of a 
 single symptom under the statistical nosological rubric (105), diarrhoea in 
 persons over 2 years of age. In medical nosology it has long been recognized 
 that these diarrhoeas may be associated not only with poisonings with inorganic 
 substances (arsenic, etc.), but with organic compounds present in foods—unripe 
 and spoiled fruits and vegetables in common use, spoiled meats (including 
 shellfish and other fish), spoiled milk and milk products, polluted waters, and 
 particularly vegetables and fruits naturally poisonous to man (certain species 
 of mushrooms, for example). The diarrhoeas following the ingestion of spoiled 
 food, attributed in the earlier days of bacteriology to special poisonous products 
 produced by the action of the bacteria of putrefaction, were later ascribed partly 
 or entirely to infections with specific bacteria ( B . enteritidis, B.paratyphosus, 
 B. coli y etc.). Similarly, the non-specific diarrhoeas associated with drinking 
 polluted waters and so common before the days of water purification have been 
 attributed to bacteria, though the particular species of offending organisms have 
 not by any means been satisfactorily identified. Infestion of the intestine by 
 various species of worms has been long recognized as a cause of diarrhoea, and 
 similarity in later years certain flagellate protozoa have been ascribed causal 
 roles. It is probable that in former days fatal diarrhoeas due to unrecognized 
 infestion with trichinae were not uncommon. To ill-prepared and to scanty 
 but otherwise healthy foods diarrhoeas have often been attributed. Finally, 
 there are diarrhoeas believed, apparently with good reason, to be due to disorders 
 of function of the nervous system, of which the so-called mucous colitis is 
 an example. 
 
 Since the beginning of the local records, diarrhoeal affections of adults and 
 of older children, classified in both medical and statistical nosology as diarrhoea, 
 inflammation of the bowels, cholera morbus, and cramp colic, have been credited 
 with a considerable toll of deaths. As has already been indicated, it is certain 
 that until very recently due discrimination was not exercised in the classifica¬ 
 tion of deaths between these categories and cholera infantum. An error in a 
 way even more serious has doubtless arisen from the classification under these 
 headings of deaths due to such specific diseases as Asiatic or true cholera, 
 dysentery, typhoid fever, tuberculosis (pulmonary and intestinal, both often 
 associated with looseness of the bowels), paratyphoid fever, and appendicitis. 
 
 Diarrhoea occupied a position in the statistical nosology as early as 1812, but 
 did not appear again until 1820. With the exception of 1821, 1822, and 1825, 
 it was not credited with any considerable number of deaths until 1849, and in 
 many of the intervening years was entirely absent from the list of the causes 
 of death. Indeed, it was not until 1875 that this term was given constantly and 
 
242 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 consecutively the leading position in the statistical nosology for deaths from 
 this group of affections. Inflammation of the bowels, though introduced in the 
 statistical nosology as early as 1818, did not attain importance until 20 years 
 later. During the fifth, sixth, and seventh decades of the nineteenth century 
 it was a favorite rubric, and average rates of 30 or over were recorded. From 
 1871 to 1895 the averaged rates were about 18; and, with gradually diminish¬ 
 ing rates, it disappeared in 1899. The rates under this rubric were but little 
 influenced by the cholera years. Cramp colic, appearing in the list of causes 
 of death in 1812, and the accredited cause of a considerable number of deaths 
 in the second, third, and seventh decades of the nineteenth century, was 
 dropped from the statistical nosology in 1873. Cholera morbus appeared as a 
 statistical rubric from 1812 until 1913, but until 1821 carried also the deaths 
 from cholera infantum. During much of the period until 1873 it was credited 
 with relatively high rates. As elsewhere pointed out, the rates for this rubric 
 were particularly high in certain cholera years (1834, 1849, and 1854). The 
 relative importance at different periods of these four categories—diarrhoea, 
 inflammation of the bowels, cramp colic, and cholera morbus—is shown in 
 table 19. 
 
 The course of the curve of the annual mortality rates for this group of 
 affections embraced is the rubric diarrhoea (105) shows considerable fluctuation 
 (graph 5), sometimes from year to year and at other times over longer or 
 shorter terms of years. The rise and fall in the rates vary sometimes directly, or 
 in the same direction, and at other times indirectly, or the direction opposite 
 with those of cholera infantum and of dysentery. As compared with dysentery, 
 with few exceptions, not until 1850 do high and low rates for the two rubrics 
 fall in the same years. It is not until the epidemic wave of dysentery beginning 
 in 1849 that the courses of these two affections really move closely together. 
 When dysentery fell abruptly 10 years later diarrhoea did not follow. The same 
 phenomenon occurred in connection with the last dysentery epidemic, 1886- 
 1890. On the whole, however, the rates for the two show a decided tendency to 
 follow the same course. The toll of mortality has been generally much greater 
 for diarrhoea than for dysentery. The correspondences and differences between 
 the courses of the rates for cholera infantum and diarrhoea have already been 
 dwelt upon at some length. The decided effect of cholera upon the rates for 
 diarrhoea is apparent in 1832, 1834, 1849, and 1854. 
 
 At the beginning of the period, though the rates for diarrhoea were in general 
 lower than later on, their annual fluctuations were wider and years of high 
 rates were commonly succeeded by one or more years of low rates. Between 
 1835 and 1841 the annual rates were consistently low; they rose gradually 
 until 1849, and between the latter date and 1898 they were never below 50 and 
 rarely below 60. The highest rate recorded was 182 in 1854 (a cholera year). 
 The abrupt fall to 36 in 1899 in the rate which had been maintained for 12 
 years at over 100, occurring in the absence of any ascertainable changes in popu¬ 
 lation composition, legislation, general sanitary environment, or administra¬ 
 tive activity, was probably due to changes in classification of deaths as between 
 cholera infantum and diarrhoea and to the elimination from the statistical 
 nosology of inflammation of the bowels. The latter heading, once so important, 
 but for the previous 20 years attended by rates between 12 and 18, had probably 
 
FEBRILE DISEASES 
 
 243 
 
 in the last two decades of the nineteenth century carried deaths from appendi¬ 
 citis and typhilitis, and for that period at least a rate of from 12 to 15 could 
 with propriety on this account be subtracted from the rates for the rubric 
 diarrhoea. 
 
 Thus, it is evident that the figures recorded for deaths under the headings 
 embraced in the rubric diarrhoea can not be regarded as even approaching 
 accuracy, for they are subject not only to errors of classification as between 
 diarrhoea and cholera infantum, but include certainly in some years deaths from 
 cholera and probably in many years deaths from other affections, notably dysen¬ 
 tery (particularly amoebic), typhoid fever, and appendicitis. 
 
 Graph 7 (from table 20). Crude mortality rates from diarrhoea, averaged 
 by 10-year periods, from 1812 to 1920, inclusive. 
 
 The curves for the rates for diarrhoea averaged for 5- and 10-year periods 
 table 20, graphs 6 and 7) give perhaps a clearer picture of the course of the 
 mortality of this group of affections. The rates as averaged for 5 years show a 
 gradual descent from 55 in 1821-1825 to 21 in 1836-1840. During the next 
 15 years by gradual steps these rates rose to 100 in 1851-1855 but receded to 
 62 in 1856-1860. The rates rose during the following 10 years to a second 
 peak in 1866-1870 with a rate of 88. A descent in the rates to 70 by 1876-1880 
 was a prelude to an uninterrupted ascent to the highest averaged rates attained 
 at all, 109, for the quinquennium ending in 1895. Ten years later these averaged 
 rates had fallen to 17, a figure departed from but slightly during the remaining 
 15 years. The rates averaged for 10-year periods show the same fall between 
 1821 and 1840 w r ith a succeeding rise to 81 in 1851-1860, a level maintained 
 during the following 10 years. The moderate fall shown in the rates averaged 
 
244 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 for the 10-year period 1871-1880 was succeeded by a second rise maintained 
 at 92 for the 20 years 1881-1900. The sharp fall during the last 20 years 
 parallels that shown in the quinquennial rates. A striking parallel between the 
 courses of these two curves and those of cholera infantum exists up to 1880, 
 but between this date and 1900 the former rose while the latter fell, and during 
 the 20 years 1901-1920 the fall for diarrhoea was much more abrupt than that 
 for cholera infantum. The divergent courses of these curves after 1880 was 
 probably due, as previously explained, more largely to changes in the classifi¬ 
 cation of deaths as between those two rubrics than to actual variations in their 
 respective rates of mortality. 
 
 It is especially worthy of note that the averaged rates for the quinquennial 
 periods ending in 1840 and 1910 were identical, i. e., 21, and that in each case 
 the low point was attained after a prolonged era of exceptionally high rates, 
 in the last instance covering a period of 60 years. Considered from this view¬ 
 point, diarrhoea, like cholera infantum, presents strong evidence of having run 
 a course of two sharply defined cycles. The first, beginning perhaps long before 
 the date of this record (1812), is viewed only in its period of decline, which 
 covered at least the 20 years 1821 to 1840. The second cycle, ranging over a 
 period of 70 years, 1841 to 1910, is in full view. It takes the form of a pro¬ 
 longed single wave of high death-rates, broken at intervals of from 15 to 20 
 years by three minor or subsidiary waves, with the rise and fall of the major 
 wave almost equally abrupt. 
 
 Data for the influence of color, sex, and age upon the mortality morbidity 
 for diarrhoea are lacking. The distribution of deaths according to season agrees 
 with that for cholera infantum. 
 
 The prevalence and serious menace of diarrhoea (105) were never alluded to 
 in the reports of the health department. 
 
 The field having been cleared in this preliminary consideration of the two 
 statistical subdivisions of the diarrhoeal affections, the study of the force of 
 mortality of this group as a whole upon the population may be undertaken. 
 
 By combining the rates for cholera infantum and diarrhoea (tables 19 and 
 20, graphs 5, 6, and 7) the inaccuracies incident in both divisors and dividends 
 and in classification inherent in calculating rates for these causes separately 
 are largely though not entirely overcome. Omitting as unnecessary detailed 
 description of the courses of the curves for annual rates and for rates averaged 
 for 5- and 10-year periods, and confining consideration to a broad view, certain 
 important features stand out with distinctness. They may be summarized as 
 follows: 
 
 On the whole, and particularly up to 1880, the course of the curves is deter¬ 
 mined by cholera infantum. 
 
 Since 1812 the curves describe two long waves, the first extending from an 
 unknown date to about 1845 and the second running from the latter date to 
 about 1900. 
 
 The highest averaged rates and the highest annual rate occurred during the 
 peak of the first wave and before 1820. 
 
 The second wave reached its peak (about 1860) within the first 15 years of 
 the 55 years of its duration. Its decline was slow and hesitating until 
 after 1890. 
 
FEBRILE DISEASES 
 
 245 
 
 About 1900, the course of mortality, having reached approximately the same 
 low level it had attained in 1845, failed to run into a third wave, but, contrary 
 to previous experience, it continued to decline to a lower level than ever before 
 registered and during the past 10 years has shown a tendency to stabilize 
 around a rate of 100. 
 
 From the position of high importance occupied during most of the period 
 between 1812 and 1825 and between 1850 and 1870, the affections under con¬ 
 sideration became relatively unimportant causes of death by 1915. 
 
 DYSENTERY. 
 
 While the course of dysentery has been marked by rather wide fluctuations 
 (table 19, graph 8) since its appearance in the local statistical nosology in 
 
 Graph 8 (from table 19). Annual crude mortality rates from diarrhoea, 
 dysentery, asiatic cholera, and typhoid fever, from 1812 to 1920, inclusive. 
 
 1814, the variations from year to year have not, in general, been great. Much 
 more characteristic has been the occurrence of epidemic waves appearing from 
 time to time, in which, from a comparatively low basic level, the rates have 
 ascended sharply, usually by uneven steps, during 3 or 4 years, to a peak, to 
 fall again, often in the same irregular fashion. 
 
 Study of the annual rates discloses six distinct waves of mortality. The 
 first wave, starting in 1815 and ending in 1824, rose sharply, but with several 
 remissions, to a peak in 1820 (111) from which it receded to a low level in 
 1824 with a rate (19) but very little above that of 1814. The peak (with a 
 rate of 64) of the second wave, a very short one, was attained in 1826, and the 
 succeeding rapid decline reached its low point (12) in 1829. The third wave, 
 
246 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 with its peak in 1832 (58), receded slowly and irregularly to the lowest 
 level (5), yet observed in 1846. The fourth wave, beginning in 1847 and attain¬ 
 ing in 1850 the highest level of mortality (145), in the history of the disease 
 and declining sharply in 1851, reacted in 1852-1854 with rates of 128, 136, 
 and 137, respectively. It then turned to reach by hesitating steps the low point 
 of 19 in 1862. The fifth wave, quite different in its course from its predecessors, 
 began in 1863, attaining rates around 30 in only 4 of the succeeding 8 years, 
 and declined gradually to the low level of 12 in 1884. The sixth and last wave, 
 occupying the years between 1885 and 1920, attained its peak of 49 in 1890, 
 and after a sharp recession to a rate of 4 in 1891 and an abrupt rise to 24 
 in 1892, it gradually declined. Since 1910 the mortality from dysentery has 
 
 Graph 9 (from table 20). Crude mortality rates from diarrhoea, dysentery, 
 asiatic cholera, and typhoid fever, averaged by 5-year periods, from 1812 
 to 1920, inclusive. 
 
 been almost negligible. Years of conspicuously high death-rates were 1820 (97), 
 1850 (145), 1852 (128), 1853 (136), and 1854 (138). The fourth wave, as 
 measured by the height of rates registered and the number of years during 
 which high rates were maintained, was by far the most severe. 
 
 Turning now to the rates averaged for 5-year periods (table 20, graph 9), 
 three major epidemic periods (1815-1845, 1850-1880, 1885-1895), with their 
 peaks falling in the quinquennial periods ending in 1825, 1855, and 1890, 
 stand out with distinctness. The descent in the curve of both the first and 
 second of these waves is broken by a secondary rise. The stationary state of 
 the averaged rates as recorded between 1876-1880 and 1881-1885, and 1891- 
 1895 and 1896-1900 at about the same low level reached in 1841-1845 is 
 
FEBRILE DISEASES 
 
 247 
 
 significant. Three waves appear in the course of the curve of the rates as 
 averaged for 10-year periods. The first wave, with an average rate of 32 for 
 the period ending in 1820 and 44 for the next 10 years, had receded to 31 
 by 1840. The second wave, with its slight rise in the rates between 1841 and 
 1850, reached its high peak in 1851-1860 (93) and receded to 27 in 1861-1870. 
 The third wave, reaching abruptly its peak in 1881-1890, declined even more 
 sharply. 
 
 On analysis of the curves for the annual rates averaged for 5- and 10-year 
 periods, certain striking facts in the natural history of dysentery in Baltimore 
 come to light. During the 20 years from 1816 to 1835 it was responsible for 
 a considerable mortality, but during the next 10 years it lost so greatly in force 
 that it might well have died out. Due to the interpolation of some cause or 
 causes beginning to act between 1847 and 1850, the diseases rapidly assumed a 
 more important role than ever before, and between 1850 and 1865 it exhibited 
 an unprecedented virulence. This phase had entirely subsided by 1885, and but 
 for a final flare-up between 1887 and 1892, the disease was well started on its 
 gradual decline to well-nigh extinction. 
 
 The whole course of the disease during 106 years for which it can be followed, 
 suggests that, while securely intrenched and able to retain perennially a secure 
 foothold, from time to time conditions arose that permitted epidemic outbreaks 
 that ran very definite wave-like courses. Under usual conditions the tendency 
 seems to have been to relatively low rates of mortality. 
 
 The influence of season upon the death-rates from dysentery has been 
 striking. Davidge, Reese, Potter, and others have recorded that dysentery was 
 common and fatal at Fell’s Point in the summertime during the last years of 
 the eighteenth and the early years of the nineteenth century. The monthly 
 distribution of the deaths from dysentery given in the tables of the annual 
 reports since 1860 shows that while in many years death occurred in every 
 month, the greater number always occurred in the summer months. 
 
 Concerning the relative frequency of the two chief varieties of dysentery, the 
 bacillary and the amoebic, there are no data before 1890, when the amoebic type, 
 so distinctive also in its anatomical lesions, was first recognized. Though a 
 considerable proportion of the earlier cases studied by Councilman and 
 Lafleur (57), in 1890 and 1891 originated elsewhere, in Panama, at sea, in 
 Sparrows Point near Baltimore, and in the counties of Maryland, a large 
 moiety of the cases had never been out of the city. A certain number of these 
 cases were in stevedores who worked and lived near the harbor. Later it was 
 observed, chiefly by physicians associated with the Johns Hopkins Hospital, 
 that amoebic dysentery was by no means uncommon among residents of Balti¬ 
 more and other parts of Maryland. There is no evidence, however, that this 
 variety of dysentery formed a conspicuous proportion of the dysenteries during 
 the last epidemic wave, the peak of which was in 1890. Amoebic dysentery has 
 been comparatively rare in the city since 1900. Since this date, at least, it seems 
 to have given place to the bacillary type. From the coincidence of very fatal 
 malaria, yellow fever, and dysentery, particularly at FelPs Point, during the 
 last years of the eighteenth and the beginning of the nineteenth century, with 
 extensive shipping trade with the tropics, it is very probable that amoebic 
 dysentery was prevalent at that time and never died out. It is more likely, 
 
248 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 however, that in the earlier great waves of dysentery, and particularly that 
 between 1850 and 1870, the bacillary type was predominant. At least, during 
 this period, there existed abundant opportunities for its importation. However, 
 as both types of the disease are met with in temperate as well as tropical cli¬ 
 mates, and conditions were favorable for the importation and propagation of 
 their causal agents, in the absence of exact studies in etiology and pathological 
 anatomy, no definite conclusion can be arrived at in regard to their relative 
 frequency as a cause of death. In 1850, at the height of the second wave of 
 dysentery, according to Frick’s analysis, the disease was nearly “ four times 
 more fatal among the whites than the blacks, the numbers being for the first 
 16 to the.Id,000 inhabitants, and only 4.6 for the latter.” As between the 
 sexes the distribution of fatalities were 59 per cent among males and 41 per 
 cent among females; 90 per cent of the whole number of deaths occurred in 
 July, August, and September. 
 
 Table 24 .—Number of deaths and rate of death, 'per 100,000 
 living inhabitants, from dysentery, according to age, 1850. 
 
 Age periods. 
 
 Deaths. 
 
 Rate. 
 
 Under 1 year. 
 
 31 
 
 506 
 
 1 to 4 years. 
 
 70 
 
 380 
 
 5 to 9 years. 
 
 38 
 
 189 
 
 0 to 9 years. 
 
 139 
 
 312 
 
 10 to 19 years. 
 
 25 
 
 68 
 
 20 to 29 years. 
 
 19 
 
 55 
 
 30 to 39 years. 
 
 20 
 
 81 
 
 40 to 49 years. 
 
 9 
 
 62 
 
 50 to 59 years. 
 
 10 
 
 123 
 
 60 years and over. 
 
 15 
 
 236 
 
 Total . 
 
 237 
 
 79 
 
 Mortality rates specific for age calculated from Frick’s figures are given in 
 table 24. It will be noted that the highest rates occurred at the extremes of 
 life, 312 under the tenth and 236 over the sixtieth year. The excessively high 
 rate of 506 for the first year of life is striking, and supports the opinion else¬ 
 where advanced that an intimate relation has existed between dysentery and 
 cholera infantum in Baltimore. As regards seasonal distribution, the mortality 
 from dysentery has not departed significantly in late years from Frick’s find¬ 
 ings. The reports of the health department do not furnish data for estimating 
 the influence of age, sex, and color upon dysentery mortality in recent years. 
 Morbidity reports are completely lacking. 
 
 CHOLERA. 
 
 According to the official records, true cholera has been present in Baltimore 
 in the 7 years 1832, 1834, 1845, 1866, 1877, and 1879 (table 19, graph 8). 
 It will be noted that this disease was not recognized as present in any two 
 consecutive years. This and other evidence at hand supports the view that it 
 rarely, if ever, gained endemic foothold, but was newly imported in each year 
 
FEBRILE DISEASES 
 
 249 
 
 in which it occurred. However, in 1833 and in 1867, each immediately succeed¬ 
 ing a year of serious epidemic prevalence of the disease, the number of deaths 
 ascribed to the common indigenous diarrhoeal diseases (cholera morbus, cramp 
 colic, and cholera infantum) was decidedly greater than the average for these 
 categories. On the other hand, as the same phenomenon commonly occurred 
 during years when cholera was acknowledged to be present, it was probably 
 due to conscious or unconscious faults of diagnosis and classification, and in 
 these particular years the hidden cholera present was probably the result of 
 new importation rather than the survival of the disease over the cold weather. 
 However this may be, cholera in Baltimore has been a fortuitous visitant, and 
 always a reflection of the invasion of the disease to western Europe and thence 
 to America. 
 
 From the known history of the affection in Baltimore, it is clear that while 
 in each of the great pandemics the disease reached the city, only once, i. e., in 
 1832, did the environmental conditions favorable to its general dissemination 
 and the chance distribution and propagation of its causal agent so fall together 
 that epidemic outbreak on a great scale occurred. As the environmental con¬ 
 ditions (ready pollution of at least a part of the water-supply—wells and 
 springs—and access of myriads of flies to intestinal discharges and to food) 
 were in those times particularly favorable, it would appear that the city’s rela¬ 
 tively slight outbreaks in most cholera years were due very largely to lucky 
 chance. From the comparatively full accounts given in the annual reports of the 
 years of serious epidemics and the more circumstantial records of Jameson (49) 
 and T. H. Buckler (11), it is possible to trace the history of cholera in Balti¬ 
 more with some degree of exactness. That a visitation of cholera was inevi¬ 
 table was apparent to Hr. Jameson, the consulting physician of the board of 
 health, early in 1832. In his youth he had imbibed from his father, a physician 
 trained in Edinburgh, the Sydenham doctrine of the causal relation of “ atmos¬ 
 pheric constitutions ” to epidemic diseases in general, and this doctrine domi¬ 
 nated his thought and activities throughout his public-health career. Having 
 followed closely, through private correspondence and the public prints, the 
 course of cholera in Europe in 1830 and 1831, by February 1832, he was con¬ 
 vinced that the disease was no exception to this general law. He, therefore, 
 informed the mayor and board of health that, in his opinion, cholera was neither 
 importable nor contagious, but was caused by a peculiar epidemic constitution 
 of the atmosphere. Consequently, he held that the one thing of prime impor¬ 
 tance was to thoroughly clear the city of everything that might contaminate the 
 atmosphere. To his mind quarantine, isolation, and compulsory hospitalization, 
 as so generally advocated and practiced, were useless and wasteful of money and 
 effort. He suggested the establishment of dispensaries conveniently situated 
 for the early treatment of the poor with symptoms of cholera. For personal 
 prophylaxis, he advised temperance and restriction of diet, with the avoidance 
 of fresh fruits and vegetables. Jameson’s views were accepted by the mayor 
 and the board of health and all the measures contrary to them that were under¬ 
 taken were adopted by an unwilling administration, to whom, in Jameson’s 
 words, “ prudence dictated the propriety of deferring to the wishes of the 
 people.” On the other hand, the great mass of the people were convinced that 
 cholera was both importable and highly contagious, and on June 7, when the ship 
 
250 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 Brenda arrived from Liverpool after losing 14 out of her 123 passengers from 
 cholera during her 42 days passage, they voiced the conviction in no uncertain 
 terms. The ship, though then free from cholera cases, was held at the lazaretto 
 for the usual ventilation of baggage and cargo, and the passengers were detained 
 under observation for several days. On June 26 an ordinance was passed which 
 required stringent quarantine of both persons and ships arriving from foreign 
 and domestic ports where dangerous contagious disease existed. Persons were 
 forbidden entry to Baltimore within 14 days of their arrival from any foreign 
 country. Jameson afterwards justified his own opinion by pointing out that 
 among the 11,946 passengers arriving at quarantine between May and Novem¬ 
 ber not a solitary case of cholera was detected. 
 
 By July, cholera was rapidly making its way towards Baltimore from the 
 north and west, and on the 7th, by ordinance, the means and personnel were 
 provided for more thorough cleaning of the streets and alleys, vacant lots, 
 stables, hogpens, slaughterhouses, and other sources of nuisances, and for 
 repaving and flushing the street gutters and the liming of all cesspools and 
 privies. The board of health was authorized to take over and equip properly 
 for cholera patients the Maryland Hospital and as many private dwellings as 
 might seem necessary and to appoint an apothecary in each ward to furnish 
 medicines at all hours at the city’s expense to cholera patients. 
 
 Considerable headway was made in cleaning up the city in the 5 weeks that 
 elapsed before the first cases of cholera were recognized. From Jameson’s 
 account it appears that his influence with the mayor was sufficient to limit 
 the number of cholera hospitals to three. To one of these he attached a free 
 dispensary. In addition to the ward apothecaries, a physician was appointed in 
 each of the 12 wards for the free treatment of the poor. 
 
 As so often happens in epidemic visitations, the earliest cases were not 
 recognized. On August 4, a girl of 7 years, who lived at the corner of Baltimore 
 and Liberty streets, in one of the best sections of the city, died suddenly of an 
 affection which was later considered to be cholera. The death of an old man on 
 the same day and the death several days later of a hoy were afterwards thought 
 by Jameson to have been caused by cholera. 
 
 At a meeting of physicians called by the mayor on August 9, while it was 
 reported that diarrhoea was common, but few of those present acknowledged 
 that they had seen “ cases having the aspect of cholera in its intense stage.” 
 Dr. Jameson reported that he had seen cases of true cholera with one death at 
 one of the hospitals, and at his instance a resolution was passed declaring that 
 cholera was present in the city. On August 13, 12 deaths occurred from 
 cholera, and of these 10 were in negroes living in Buxton Lane or its neighbor¬ 
 hood. On the 20th, 55 cases were reported. 
 
 From table 25 the course of this disease as expressed by deaths may be fol¬ 
 lowed by weeks. It will be noted that the number of weekly deaths ascribed 
 both to cholera and to all causes rose steadily to a peak reached the week ending 
 September 10 and that the decline was rapid and striking during the next 4 
 weeks. The disease about held its own between October 10 and 16. The number 
 of deaths from cholera during the third week of October was double that 
 recorded in the second week. After falling during the last week of October to 
 the level reached for the second week of this month, the number of deaths rose 
 
FEBRILE DISEASES 
 
 251 
 
 again during the first week of November. After November 5, however, there 
 were but 2 cholera deaths. The greater number of cholera deaths (seven-eighths) 
 occurred in September, and one-seventh of the whole number was recorded in 
 the 7 days between the 4th and the 10th of this month. From this table it is 
 evident that the number of deaths from all causes, while rising and falling 
 direetly with the cholera deaths, was, during August, September, and October, 
 relatively much greater than accounted for by the deaths attributed to cholera. 
 During September, for instance, the number of deaths ascribed to causes other 
 than cholera was nearly double the ordinary number of deaths for this month. 
 It would appear, then, that the full influence of cholera upon the mortality 
 during the epidemic is not disclosed by the official figures of cholera deaths. 
 
 Table 25. —Number of deaths and weekly annual rate of 
 death, per 100,000 living inhabitants, from cholera 
 and all causes, during the period of the cholera epi¬ 
 demic in 1832. 
 
 Week ending. 
 
 Cholera. 
 
 All causes. 
 
 Deaths. 
 
 Rate. 
 
 Deaths. 
 
 Rate. 
 
 Aug. 14. 
 
 12 
 
 679 
 
 79 
 
 4471 
 
 20. 
 
 54 
 
 3056 
 
 127 
 
 7187 
 
 27. 
 
 121 
 
 6848 
 
 178 
 
 10074 
 
 Sept. 3. 
 
 170 
 
 9621 
 
 254 
 
 14375 
 
 10. 
 
 226 
 
 12790 
 
 332 
 
 18789 
 
 17. 
 
 135 
 
 7640 
 
 225 
 
 12733 
 
 24. 
 
 40 
 
 2264 
 
 116 
 
 6565 
 
 Oct. 1. 
 
 21 
 
 1188 
 
 89 
 
 5037 
 
 9. 
 
 12 
 
 679 
 
 68 
 
 3848 
 
 16. 
 
 10 
 
 566 
 
 52 
 
 2943 
 
 23. 
 
 25 
 
 1415 
 
 82 
 
 4641 
 
 30. 
 
 10 
 
 566 
 
 62 
 
 3509 
 
 Nov. 5. 
 
 15 
 
 849 
 
 66 
 
 3735 
 
 13. 
 
 1 
 
 57 
 
 34 
 
 1924 
 
 20. 
 
 1 
 
 57 
 
 34 
 
 1924 
 
 27. 
 
 • • • 
 
 • • • 
 
 44 
 
 2490 
 
 Total .. 
 
 853 
 
 926 
 
 1842 
 
 1999 
 
 It has been pointed out at the beginning of this study that during 183)4 the 
 death-rates for diarrhoea (105) and cholera infantum (104) were unusually 
 high. The 4 deaths from cholera already mentioned as occurring early in 
 August were not included in the 853 deaths officially credited to cholera, and 
 there were doubtless many others in the same category. On a conservative 
 estimate, considerably more than 1 per cent of the total population died of 
 cholera in this year. 
 
 Cholera attacked 211 of the 502 inmates of the almshouse, and of these 133 
 died. As the almshouse was situated without the city limits, these deaths were 
 not included in the official figures. 
 
 The records throw no light upon how the disease gained entrance to the city. 
 Whether or not cases or carriers were admitted through shipping can not now 
 be decided. At any rate, there is little doubt that the disease was introduced 
 17 
 
252 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 by means of overland communication from the north and west, where it was 
 first prevalent, and for which abundant opportunity was open. 
 
 The first openly declared cases appeared in Buxton Lane, now Balderston 
 Street, a narrow and filthy alley, a short distance southeast of Baltimore and 
 Liberty streets and in the direct line of natural drainage from the latter point, 
 where resided the girl who died on August 4 of what Dr. Jameson afterwards 
 regarded as cholera. Buxton Lane was but a short distance from Clopton's 
 Spring, one of the favorite public springs. It is not unlikely that this spring 
 was polluted early in the epidemic and was responsible, if not for the Buxton 
 Lane cases, at least for the numerous cases which, according to Jameson, later 
 occurred along Liberty Street and its vicinity. The disease subsequently spread 
 through most of the city. In some places crowded streets and alleys suffered 
 most, but there were many exceptions to this. From the character of the 
 epidemic, as judged by the time distribution of the deaths and from Jameson's 
 allusion to the gradual spread of the disease through the city, it would seem 
 likely that its chief means of dissemination was by means of the wells and 
 public springs, which perhaps became polluted in rotation as the infective agent 
 was carried from one part of the city to another by persons infected in other 
 localities. It is quite possible tliat the external water-supply may have been 
 infected for a time at least. There was, of course, ample opportunity for spread 
 of the diseases by means of flies, which must have existed in great numbers. As 
 much of the milk-supply was derived from cows kept within the city, opportuni¬ 
 ties for the infection of this article of food were peculiarly favorable. 
 
 There is no record of the whole number of cases reported, nor are there data 
 regarding the influence of age, sex, and color upon either incidence or mor¬ 
 tality. According to Jameson, “a very great majority of those who died 
 were of the most worthless; but a few of our respectable citizens fell vic¬ 
 tims ....,'' a blunt way of saying that the disease was more prevalent and 
 fatal among the poor and ill-nourished than among the well-to-do. 
 
 Out of the nearly 100 physicians of the city, a few had the disease and one 
 died. From this it would appear that the mortality rate among physicians was 
 about the same as that for the population as a whole. Two out of an unknown 
 number of Catholic sisters, who acted as voluntary nurses in cholera hospitals, 
 died of the disease. Of the 387 cases admitted to the cholera hospitals, 170 
 died, a case fatality-rate of 44 per cent. However, as it is recorded that many 
 were moribund on admission and that such was the dread of the hospitals 
 that few who had homes and could receive any attention in them would consent 
 to be removed, these figures can not be taken as a correct index of the propor¬ 
 tion of cases to deaths in the whole population. 
 
 From Jameson's account, the plan of medical treatment of the hospital 
 cases—copious blood letting, purging with calomel and aloes and croton and 
 castor oils, blistering with cantharides, and the like, was not calculated to 
 diminish the fatality rate. It is of interest that following the lead of Diffen- 
 bach, of Berlin, and of certain physicians of Hew York and of Norfolk, 
 Virginia, Jameson experimented with intravenous injections of common salt 
 and water. While temporary improvement followed in some cases, all patients 
 so treated died. His experience with injections of plain water and aqueous 
 solution of nitrate of potash was similar. 
 
FEBRILE DISEASES 
 
 253 
 
 The data concerning the cholera of 1834 are very scanty. Jameson recorded 
 that a few doubtful cases occurred in the summer, but that in November there 
 was a sudden outbreak. During this month there occurred 71 deaths, the whole 
 number recorded for this year. The cholera hospital was opened on November 
 8 and closed on December 6. As Jameson regarded the doubtful cases of the 
 summer, as well as those of November, as cases of cholera morbus or “ con¬ 
 secutive cholera .... made to assume the livery of cholera from a predis¬ 
 position or impression left in the system by the epidemic atmosphere of 1832,” 
 and as rates for diarrhoea and cholera infantum jumped, as in 1832, to unusu¬ 
 ally high levels, there is good reason for the inference that cholera was much 
 more widespread and fatal in 1834 than the official figures indicate. 
 
 The correctness of the diagnosis in connection with the single death ascribed 
 to cholera in 1845 is open to question. No mention was made in the annual 
 report of the presence of this disease in the city or at the quarantine station, 
 and there was no significant change in the rates for the diarrhceal affections. 
 
 Cholera was undoubtedly prevalent to some extent within the city in 1849, 
 though no deaths were credited to it, and no allusion was made to the disease 
 in the annual report of the health department. 
 
 T. H. Buckler (11) wrote a very complete account of a serious epidemic of 
 cholera at the almshouse in 1849. The first case occurred on July 1 and the 
 last on August 8; the first death took place on July 11 and the last on 
 August 5. During the first two weeks the progress of the disease was slow 
 and hesitating (single cases on July 1 and 7, 3 each on the 11th and 12th, 
 and 1 case on the 13th). The peak came abruptly and lasted 10 days with 
 relatively little daily variation in the number of cases (13 cases on the 14th 
 and a daily average of 10 new cases from the 15th to the 24th). The decline 
 was as sharp and as long drawn out as the approach (3 cases on the 25th and, 
 with the exception of 4 cases on the 27th and 5 on the 30th, never more than 
 3 a day, and a total of 8 cases between August 1 and 8). The distribution of 
 deaths according to days followed that of the cases very closely during the 
 height of the epidemic. 
 
 The population of the almshouse when cholera broke out was 560, of whom 
 407 were whites and 153 blacks; but during the epidemic there were 109 
 admissions and 153 emissions. The latter embraced 56 discharges, 76 elope¬ 
 ments, and 21 dead from causes other than cholera. Altogether, 669 individ¬ 
 uals were exposed to risk of attack and death from cholera, but their degree of 
 exposure was not the same. On this account it is not possible to calculate 
 precise morbidity and mortality rates. There were recognized 155 cases of true 
 cholera; of these 86 died, and on the basis of a population of 669 exposed in 
 some degree, the attack and mortality rates were 23 per cent and 12.8 per cent 
 respectively. Among the whites there were 112 cases with 57 deaths and among 
 the negroes 43 cases with 29 deaths; thus the case fatality rates were: Whites 
 50 per cent, negroes 67 per cent, total 55.5 per cent. However, according to 
 Buckler, the number of each sex admitted, discharged, and eloped during July 
 bore a very uniform ratio to the proportion of males and females present at 
 the beginning of the month. On the female side of the institution there were 
 on July 1, 322, and in this department 62 had cholera and 38 died; the males 
 at the same date numbered 238, and on this side there were 93 cases of cholera. 
 
254 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 with 48 deaths. Using these figures as a basis, the attack, death, and case- 
 fatality rates were: For females 19 per cent, 11 per cent and G1 per cent, and 
 for males 39 per cent, 20 per cent, and 50 per cent, respectively. According to 
 these approximate figures, the attack and death rates were twice as great in 
 males as in females, and the case fatality was somewhat higher in females than 
 in males. 
 
 As from Buckler’s account it is probable that the infection was not spread 
 by the water-supply derived from a nearby stream called Rutter’s Run, at a 
 point above the institution, but rather by personal contact and by flies, since 
 the disease was not uniformly distributed throughout the institution and the 
 great bulk of the cases developed among those who were housed in the wings 
 facing north and east and directly overlooking a huge open cesspool which 
 received all the drainage. Draining and cleaning the cesspool by ditching and 
 flushing was started on July 23 and finished on the 25th, the date of the 
 beginning of the decline in the attack rate. Three days later the whole area 
 of this pond of fecal discharge was covered with several bushels of unslaked 
 lime overlay ed with fresh earth, and after July 28 only 18 additional cases 
 occurred. Two of the three laborers employed in this work developed cholera 
 on July 29 at their homes in the city. According to the fashion of the day, 
 Buckler attributed the outbreak to miasma from the open cesspool. 
 
 Though not officially recognized, cholera was certainly present in the city 
 during this year. Besides the two laborers above mentioned, Buckler saw 3 
 cases late in July and on September 15 attended another case in a man who 
 was taken sick shortly after arriving from Cincinnati. According to him, a 
 mild “ cholorine ” prevailed during the summer in nearly every section of the 
 city. Though no deaths were recorded from cholera, the death rates from 
 diarrhoea and cholera infantum were conspicuously higher than during the 
 previous year. 
 
 No cases of cholera were discovered on ships arriving at quarantine. It is 
 certain that the disease was brought in by overland travelers at least once during 
 the year, and it is probable that sporadic cases secondary to imported cases 
 occurred widely during the hot weather. The disease was probably introduced 
 into the almshouse by a pauper from the city. That the city escaped a wide¬ 
 spread water-borne epidemic is due to the fact that Rutter’s Run, into which 
 the almshouse cesspool drained, was a tributary of Gwynn’s and not of Jones 
 Falls. 
 
 In 1854, a few sporadic cases of cholera, with 2 deaths, were acknowledged 
 by the health department. These were regarded as secondary to a small out¬ 
 break just without the western border of the city. One case of cholera was 
 recorded at the Marine Hospital, but this was possibly received from the city. 
 In this year not only were deaths from the diarrhoea! diseases considerably 
 higher than during the preceding year, but the increase was most marked in 
 the categories most likely to hide cholera, namely, cholera morbus and cramp 
 colic. In 1854, the deaths from the former were 129 and from the latter 111, 
 in contrast to 11 and 28, respectively, in 1853. The total rate for diarrhoea 
 was 182, or more than double the rates for 1853 and 1855. There is ample 
 reason, therefore, for the inference that cholera was epidemic in the city in 
 1854 and was responsible for a death-rate of at least 100. 
 
FEBRILE DISEASES 
 
 255 
 
 Judging from the monthly distribution of the recorded deaths from the 
 disease, 54 in October and 6 in November, the outbreak of recognized cholera 
 in 1866 probably began after the middle of September. It is unlikely, however, 
 that this disease was more widely spread and fatal than the official figures 
 indicate, for the death-rates from both cholera infantum and diarrhoea were not 
 significantly higher than in the years immediately preceding. Though cholera 
 approached the city by water, a case being removed from a vessel at quarantine 
 during the summer, the health authorities were perhaps correct in their asser¬ 
 tion that the first cases came overland, one from New York and the other 
 from Cincinnati. Their attitude towards the disease was quite different now. 
 Theories of “ atmospheric constitutions ” and of miasma no longer befogged' 
 their minds. Snow’s discovery of some 16 years before that epidemic cholera 
 was largely ^waterborne, and the popular view that the disease might be con¬ 
 veyed somehow by personal relation with cholera patients, were taken seriously. 
 Action direct and personal became the order of the day; the sick and their 
 discharges, clothing, and utensils were recognized as vehicles by which the 
 mysterious cause was disseminated. Measures were adopted to secure the 
 removal and destruction of everything used by those affected with the disease, 
 and the disinfection and burial of their discharges. In appropriate instances 
 both the sick and the exposed were removed to the quarantine hospital. 
 
 “ In Elbow Lane, in one square, 20 cases occurred in 2 days; the crowded condi¬ 
 tions of the houses, the filth of the houses and of the people (negroes) we thought 
 justified extreme measures. Every person, both sick and well, was removed to the 
 quarantine grounds, the sick put in the hospital and the others in barracks. Not a single 
 case occurred after removal, either in the alley or in the removed persons. But one of 
 those attacked recovered.” 
 
 Everything used by the sick was destroyed, the houses were fumigated, and 
 after 10 days the well people were allowed to return; no subsequent cases 
 occurred in this group. 
 
 No allusion is made to cholera in the annual reports for 1877 and 1879. 
 From the comparatively small number of deaths and the absence of any striking 
 increase in the rates from diarrhoea and cholera infantum, it is probable that 
 the disease was confined to a few sporadic cases. No cases were discovered in 
 connection with shipping. 
 
 Unfortunately, for none of the cholera years is there any record of the number 
 of cases or of the distribution of the deaths according to the age, sex, or color 
 of the decedents. 
 
 Thus runs the history of cholera in Baltimore. Though incomplete in many 
 details, it is sufficiently accurate for a fairly correct picture. Attention may 
 here be directed to certain points of particular importance. While the official 
 figures of deaths ascribed to cholera are probably lower than the actual number 
 of deaths from this disease in every year in which cholera occurred, they are 
 particularly far short of the truth for 1849 and 1854. In these two years, at 
 least, the health authorities deliberately sought to hide the truth. The great 
 influence of cholera in 1832 and 1834 upon the total death-rate from acute 
 intestinal diseases for the quinquennium 1831-1835 and the decennium 1831- 
 1840 is shown by the fact that by the official figures alone the cholera deaths, 
 raised the averaged rates for the former period by 200 and for the latter period 
 by 100. If, for the period, 1831-1835, all the deaths really due to cholera but 
 
256 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 which were credited to cholera infantum and diarrhoea could be properly classi¬ 
 fied, it would appear that, but for the advent of cholera, the decline in the total 
 rate for the acute intestinal diseases would have been unbroken. As it is, when 
 the rates for cholera calculated from the official figures, without such allowance, 
 are subtracted from the rates averaged for the 10 years 1831-1840, the decline 
 in the curve is almost continuous. Similarly, a not inconsiderable portion of 
 the ascent in the total rates for acute intestinal affections between 1849 and 
 1860 was due to the influence of cholera in 1849 and 1854. 
 
 On the whole, in comparison with certain other cities, Baltimore’s experience 
 with cholera was not unlucky. In but one year, 1832, was the toll from cholera 
 relatively serious. 
 
 TYPHOID FEVER. 
 
 The term typhoid fever did not appear in the local statistical nosology until 
 1851. However, there is convincing evidence that the disease was not uncommon 
 in the city long before this date. The report of the attending physicians of the 
 almshouse infirmary in 1828 mentions 58 cases of fehris typhoides, with 13 
 deaths. Typhoid fever was credited in these reports with cases and deaths 
 every year but one between 1833 and 1849, and during these 17 years there was 
 a total of 359 cases with 106 deaths. E. Geddings (58), under the title of 
 “ gastric, or more properly intestinal fever,” described a continuous fever of 
 grave type which was very prevalent in 1834; 80 casese were admitted to the 
 Baltimore Infirmary during the summer of this year. It was especially common 
 at EelPs Point, and many of the patients were sailors who were attacked after 
 their arrival. Some of the victims were brought in from the nearby rural 
 districts. From Gedding’s description of the clinical symptoms and of the 
 ulcers of the small intestine in fatal cases, there can be little doubt that he was 
 dealing with true typhoid fever. It would also appear that gastric fever was 
 commonly used as a synonym for typhoid fever. 
 
 Buckler (11) is authority for the statement that typhoid fever was very 
 prevalent in grave form among the inmates, resident physicians, and students 
 at the almshouse between 1846 and 1849 inclusive. During the last three of 
 these years the wards were never free from cases. In 1847, Frank Donaldson 
 demonstrated the intestinal lesions of typhoid fever in an immigrant dying at 
 the Marine Hospital, and sent to the almshouse infirmary 2 cases of the disease 
 removed from ships. The annual reports of the quarantine officer about this 
 date and later mention not infrequently cases of this affection. 
 
 There were not lacking in Baltimore in 1840 able physicians, who were 
 familiar with the natural history of typhoid fever. Among them were Professor 
 Elisha Bartlett, who wrote his epochal book on Continued fevers here in 1842, 
 Professor William Power, a pupil of Louis, and Thomas H. Buckler. The 
 presence of this disease in Baltimore as early as 1812 is attested by the use of 
 the term nervous fever, the old German name for typhoid fever, in the statisti¬ 
 cal nosology. It is not unlikely that the few cases of typhus mitior mentioned 
 in the reports of the censors of the Medical and Chirurgical Faculty in 1809 
 and 1811 were typhoid fever. 
 
 When typhoid fever first made its appearance in Baltimore can not be 
 ascertained. It is likely that it gained a foothold at an early date and became 
 gradually more prevalent during the period of enormous growth of the city 
 
FEBRILE DISEASES 
 
 257 
 
 between 1790 and 1830. From the increasing prevalence of the disease at the 
 almshouse after 1845, and the first mention of cases in connection with shipping 
 about this time, it is likely that it w'as imported on a large scale by the immi¬ 
 grants who poured in from Ireland and Germany between 1845 and 1860. 
 It was doubtless very largely confused with malarial and typhus fevers, and 
 between 1812 and 1850 was probably hidden in the statistical nosology under 
 these headings as well as under nervous and gastric fevers and inflammation 
 of the bowels. While up to 1850 the course of the disease can be traced but 
 imperfectly as nervous and gastric fevers, after this date it can be followed with 
 some degree of accuracy. Typhus fever probably, and malaria, inflammation 
 of the bowels, diarrhoea, and gastric fever certainly, continued for some time 
 to be credited with deaths due to typhoid fever. To make allowance for evident 
 statistical errors of this nature, deaths from nervous, gastric, and typho-malarial 
 fevers have been included in the list of typhoid-fever deaths. Deaths credited 
 to typhus fever, negligible after 1860, diarrhoea, and inflammation of the bowels 
 can not be so adjusted. 
 
 On the other hand, many deaths from other causes have been erroneously 
 classified under typhoid fever. The more common of these are pneumonia, 
 pleurisy, empyema, influenza, appendicitis, suppurative processes of the liver 
 and of the biliary and urinary tracts, acute miliary tuberculosis, various cryp¬ 
 togenic suppurative infections, acute endocarditis, pyemia, and septicemia— 
 the large group of affections often included under the term typhoid state. 
 Conversely, deaths from typhoid fever have been credited to these. A decidedly 
 unfavorable influence upon the Baltimore mortality rate from typhoid fever 
 has been exerted by the deaths of non-residents, particularly from rural Mary¬ 
 land, brought to the city for treatment. During 1917 to 1919, inclusive, such 
 persons were responsible for 20 per cent of the recorded deaths from this disease. 
 Though the data upon which the mortality rates for typhoid fever are calculated 
 are by no means exact, the rates probably approximate the truth closely enough 
 to indicate the general trend of the curve of mortality during the period under 
 consideration. 
 
 From table 19 it is seen that there were deaths recorded from nervous fever 
 in each year but two from 1812 to 1824 and in every year from 1843 to 1845 
 and from 1848 to 1850 inclusive. Deaths were ascribed to gastric fever from 
 1837 to 1875 and 1878 to 1884 inclusive, and again in 1886. Typho-malarial 
 fever, occurring first in 1876, was given as a cause of death from 1879 to 1898 
 inclusive. It is strange that gastric fever, which according to Geddings was 
 a prevalent and fatal disease within the city in 1834, was not credited with 
 deaths before 1837. 
 
 From the annual rates (table 19, graph 8) it is evident that typhoid fever 
 as nervous fever was the cause of a not inconsiderable but fluctuating annual 
 mortality between 1812 and 1824. Between 1825 and 1836 there is a complete 
 absence of deaths ascribed to known synonyms of typhoid fever. The compara¬ 
 tively low annual rates from 1837 to 1842 are based on deaths recorded under 
 gastric fever. Between 1843 and 1850 there was a considerable rise in the 
 rates for gastric fever, and in all but two years a few deaths were credited to 
 nervous fever. The highest rate so far attained was 27, in 1845. After 1850, 
 with the appearance of typhoid fever in the nosology, the rates for gastric 
 
258 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 fever underwent a sudden and permanent fall. The entrance of the term 
 typhoid fever into the statistical nosology in 1851 was marked by an increase 
 in the rate by 165 per cent over the previous year. Rising from 53 in 1851 and 
 1852 to 67 in 1853, the annual rates fell gradually to 42 in 1856. By 1860 
 the rates had risen to the level of 1851, and, continuing their ascent, they 
 reached 80 in 1861 and 94 in 1862. Remaining high, but with considerable 
 fluctuations from year to year, the annual rates attained their highest point, 
 106, in 1870. After this date the annual rates declined slowly and hesitatingly, 
 sometimes with but slight variation, for a period of several years, and now and 
 again with sharp rises and declines. By 1886 the rates had fallen to the level 
 of 1851. After remaining at about 52 for 4 years, there was another period of 
 fluctuation lasting until 1895. After stabilizing around 40 for 4 years, the 
 rates descended again, and by 1901 had reached 27. From this point there 
 was a sharp reaction covering the next 8 years, during which the rates reached 
 42 in two years. In 1909 the rate dropped to 24. In 1910 there was a reaction 
 to 41, succeeded by a fall to 26 in 1911. During the succeeding 4 years the 
 rates were almost stationary at an average rate of 22. From 1916 the rates 
 fell continuously, and at a more rapid rate each succeeding year, to 5 in 1920. 
 
 In studying the curve of the rates averaged for 5-year periods (table 20, 
 graph 9), the periods before 1835 may be disregarded. Beginning with a rate 
 of 4 for the quinquennium ending in 1840, the rates rose rapidly during the 
 next 15 years and had attained 58 by 1851-1855. After a drop to 48 for the 
 period ending in 1860 there was a jump to 82 in 1861-1865, and 87 was 
 reached in 1870. From this high peak the rates declined sharply during the 
 next 10 years to 61. After remaining practically stationary between 1876- 
 1880 and 1881-1885, there was a somewhat uneven decline to 12 in 1916-1920. 
 
 For the rates as averaged for 10-year periods (table 20, graph 10), the curve 
 is so smoothed that the rise in the rates from 1841-1850 to a peak in 1861-1870 
 and the fall afterwards are both continuous. The angle of the ascent is, however, 
 much more acute than that of the descent. The rate of the fall for the 30 years, 
 1870 to 1900, was fairly even. It slowed up materially for the next 10 years, 
 but between 1910 and 1920 it was considerable. 
 
 On comparing the curves for typhoid fever and for dysentery and diarrhoea, 
 on the basis of the annual rates averaged for 5-year periods, it is observed that 
 between 1815 and 1830 the three rose and fell together, and the correspondence 
 in the shape of the curves for typhoid and dysentery is remarkably close. 
 Between 1840 and 1855 the three again rose together, and all reached a peak 
 in the latter year. They fell together between 1855 and 1860. While typhoid 
 and diarrhoea reacted to another peak attained in 1866-1870 and fell together 
 during the succeeding 10 years, dysentery fell decidedly between 1860 and 1865, 
 reacted only slightly in 1866-1870, and then fell continuously and sharply 
 until 1886-1890. On the other hand, when diarrhoea began in 1890 a sharp 
 rise which culminated in 1891-1895, and dysentery rose to a peak in 1886-1890, 
 typhoid fever pursued its gradual decline uninterruptedly. The considerable 
 fall in the rates for diarrhoea and dysentery which occurred between 1900 and 
 1910 were not associated with a correspondingly acute fall in the rate for 
 typhoid fever. In a general way, therefore, the courses of the curves for these 
 three acute intestinal diseases of different etiology but with the same modes 
 
FEBRILE DISEASES 
 
 259 
 
 of spread are rather closely alike during some parts of the period under con¬ 
 sideration; at others they deviate widely. 
 
 Data are available from 1889 to 1919, inclusive, for calculating mortality 
 rates according to color and sex. These are set forth in table 26. The rates for 
 the white population follow closely those for the whole population, but those 
 for the former exceed those for the latter slightly in 1893, and the rates for 
 the two are equal in 7 years—in 1892, 1896, 1897, 1908, 1912, 1916, and 1919. 
 The white rates are lower than the negro rates, except in 1893 and 1896, and 
 the rates for the two races are equal in 1892, 1908, and 1916. The rates for 
 white females exceed those for the males and for the whole population in 1892 
 
 YEAR 
 
 Graph 10 (from table 20). Crude mortality rates from diarrhoea, dysen¬ 
 tery, asiatic cholera and typhoid fever, averaged by 10-year periods, from 
 1812 to 1920, inclusive. 
 
 and 1893, are decidedly lower than the other two after 1894, and in general 
 follow closely the rise and fall of the other rates, particularly those for total 
 white and the total population. The rates for white males, except in 1892 and 
 1893, are uniformly higher than those for white females and for the total 
 white population. 
 
 The annual fluctuations in the rates for colored are much greater than in 
 those for the white population, and therefore the courses of their curves are 
 much less smooth. The curve for the total negro rate falls considerably below 
 those for the whole population and for the whites in 1893, but otherwise it 
 is considerably higher. The rates for negro females are much lower than those 
 for negro males, except in 1891, 1893, 1901, and 1913, when the converse 
 is true. 
 
260 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 It is clear that the mortality rates for typhoid fever have been markedly 
 influenced by race and sex. Since the rates for the negro population are much 
 higher than those for the white, and the rates for females of both races are 
 lower than those for males, the total rate is influenced favorably by a low 
 proportion of negroes and high proportion of females in the population. 
 
 The age distribution of the deaths from typhoid in 1910 is given in table 27. 
 
 Table 26 . —Number of deaths and rate of death, per 100,000 living inhabitants, from 
 typhoid fever, according to color and sex, from 1889 to 1920, inclusive. 
 
 D = death. R = rate. 
 
 Year. 
 
 Total. 
 
 White. 
 
 Colored. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 1889 
 
 • • • • 
 
 224 
 
 52 
 
 111 
 
 55 
 
 113 
 
 50 
 
 181 
 
 50 
 
 88 
 
 51 
 
 93 
 
 49 
 
 43 
 
 66 
 
 23 
 
 81 
 
 20 
 
 55 
 
 1890 
 
 • • • • 
 
 301 
 
 69 
 
 161 
 
 78 
 
 140 
 
 61 
 
 244 
 
 66 
 
 135 
 
 76 
 
 109 
 
 57 
 
 57 
 
 86 
 
 26 
 
 90 
 
 31 
 
 84 
 
 1891 
 
 • • • • 
 
 189 
 
 43 
 
 95 
 
 45 
 
 94 
 
 40 
 
 157 
 
 42 
 
 82 
 
 46 
 
 75 
 
 38 
 
 32 
 
 48 
 
 13 
 
 44 
 
 19 
 
 51 
 
 1892 
 
 • • • • 
 
 226 
 
 50 
 
 100 
 
 47 
 
 117 
 
 49 
 
 192 
 
 50 
 
 90 
 
 49 
 
 102 
 
 51 
 
 34 
 
 50 
 
 19 
 
 63 
 
 15 
 
 39 
 
 1893 
 
 • • • • 
 
 255 
 
 56 
 
 119 
 
 55 
 
 136 
 
 57 
 
 228 
 
 59 
 
 108 
 
 58 
 
 120 
 
 60 
 
 27 
 
 39 
 
 11 
 
 36 
 
 16 
 
 41 
 
 1894 
 
 • • • • 
 
 257 
 
 55 
 
 126 
 
 57 
 
 131 
 
 54 
 
 207 
 
 53 
 
 103 
 
 54 
 
 104 
 
 51 
 
 50 
 
 71 
 
 23 
 
 74 
 
 27 
 
 69 
 
 1895 
 
 • • • • 
 
 192 
 
 41 
 
 103 
 
 46 
 
 89 
 
 36 
 
 157 
 
 39 
 
 82 
 
 43 
 
 75 
 
 36 
 
 35 
 
 49 
 
 21 
 
 66 
 
 14 
 
 35 
 
 1896 
 
 • • • • 
 
 204 
 
 43 
 
 109 
 
 48 
 
 95 
 
 38 
 
 174 
 
 43 
 
 93 
 
 48 
 
 81 
 
 39 
 
 30 
 
 41 
 
 16 
 
 49 
 
 14 
 
 34 
 
 1897 
 
 • • • • 
 
 209 
 
 43 
 
 119 
 
 51 
 
 90 
 
 35 
 
 175 
 
 43 
 
 99 
 
 50 
 
 76 
 
 36 
 
 34 
 
 46 
 
 20 
 
 61 
 
 14 
 
 34 
 
 1898 
 
 • • • • 
 
 201 
 
 41 
 
 115 
 
 49 
 
 86 
 
 33 
 
 158 
 
 38 
 
 96 
 
 48 
 
 62 
 
 29 
 
 43 
 
 57 
 
 19 
 
 57 
 
 24 
 
 57 
 
 1899 
 
 • • • • 
 
 153 
 
 31 
 
 85 
 
 36 
 
 68 
 
 26 
 
 119 
 
 28 
 
 67 
 
 33 
 
 52 
 
 24 
 
 34 
 
 44 
 
 18 
 
 53 
 
 16 
 
 38 
 
 1900 
 
 • • • • 
 
 189 
 
 37 
 
 104 
 
 43 
 
 85 
 
 32 
 
 152 
 
 35 
 
 83 
 
 40 
 
 69 
 
 31 
 
 37 
 
 48 
 
 21 
 
 61 
 
 16 
 
 37 
 
 1901 
 
 • • • • 
 
 141 
 
 27 
 
 77 
 
 31 
 
 64 
 
 24 
 
 110 
 
 25 
 
 66 
 
 31 
 
 44 
 
 20 
 
 31 
 
 39 
 
 11 
 
 31 
 
 20 
 
 46 
 
 1902 
 
 • • • • 
 
 220 
 
 42 
 
 123 
 
 50 
 
 97 
 
 36 
 
 172 
 
 39 
 
 99 
 
 46 
 
 73 
 
 32 
 
 48 
 
 60 
 
 24 
 
 67 
 
 24 
 
 54 
 
 1903 
 
 • • • • 
 
 189 
 
 36 
 
 105 
 
 41 
 
 84 
 
 31 
 
 137 
 
 31 
 
 79 
 
 36 
 
 58 
 
 25 
 
 52 
 
 64 
 
 26 
 
 71 
 
 26 
 
 58 
 
 1904 
 
 • • • • 
 
 199 
 
 37 
 
 117 
 
 46 
 
 82 
 
 30 
 
 158 
 
 35 
 
 91 
 
 41 
 
 67 
 
 29 
 
 41 
 
 50 
 
 26 
 
 70 
 
 15 
 
 33 
 
 1905 
 
 • • • • 
 
 197 
 
 36 
 
 108 
 
 42 
 
 89 
 
 32 
 
 158 
 
 35 
 
 85 
 
 38 
 
 73 
 
 31 
 
 39 
 
 47 
 
 23 
 
 61 
 
 16 
 
 35 
 
 1906 
 
 • • • • 
 
 183 
 
 33 
 
 108 
 
 41 
 
 75 
 
 26 
 
 141 
 
 31 
 
 83 
 
 37 
 
 58 
 
 24 
 
 42 
 
 49 
 
 25 
 
 65 
 
 17 
 
 36 
 
 1907 
 
 • • • • 
 
 230 
 
 42 
 
 139 
 
 52 
 
 91 
 
 32 
 
 180 
 
 39 
 
 112 
 
 49 
 
 68 
 
 28 
 
 50 
 
 58 
 
 27 
 
 70 
 
 23 
 
 49 
 
 1908 
 
 • • • • 
 
 180 
 
 32 
 
 103 
 
 38 
 
 77 
 
 27 
 
 152 
 
 32 
 
 84 
 
 36 
 
 68 
 
 28 
 
 28 
 
 32 
 
 19 
 
 48 
 
 9 
 
 19 
 
 1909 
 
 • • • • 
 
 136 
 
 24 
 
 85 
 
 31 
 
 51 
 
 17 
 
 107 
 
 22 
 
 67 
 
 29 
 
 40 
 
 16 
 
 29 
 
 33 
 
 18 
 
 45 
 
 11 
 
 23 
 
 1910 
 
 • • • • 
 
 235 
 
 41 
 
 124 
 
 45 
 
 111 
 
 38 
 
 192 
 
 40 
 
 101 
 
 43 
 
 91 
 
 37 
 
 43 
 
 48 
 
 23 
 
 57 
 
 20 
 
 41 
 
 1911 
 
 • • • • 
 
 154 
 
 27 
 
 94 
 
 34 
 
 60 
 
 20 
 
 124 
 
 25 
 
 79 
 
 33 
 
 45 
 
 18 
 
 30 
 
 33 
 
 15 
 
 36 
 
 15 
 
 30 
 
 1912 
 
 • • • • 
 
 136 
 
 23 
 
 72 
 
 25 
 
 64 
 
 21 
 
 111 
 
 23 
 
 60 
 
 25 
 
 51 
 
 20 
 
 25 
 
 27 
 
 12 
 
 29 
 
 13 
 
 26 
 
 1913 
 
 • • • • 
 
 135 
 
 23 
 
 68 
 
 24 
 
 67 
 
 22 
 
 92 
 
 19 
 
 51 
 
 21 
 
 41 
 
 16 
 
 43 
 
 46 
 
 17 
 
 40 
 
 26 
 
 51 
 
 1914 
 
 • • • • 
 
 130 
 
 22 
 
 70 
 
 24 
 
 60 
 
 20 
 
 107 
 
 21 
 
 57 
 
 23 
 
 50 
 
 20 
 
 23 
 
 24 
 
 13 
 
 30 
 
 10 
 
 19 
 
 1915 
 
 • • • • 
 
 128 
 
 21 
 
 74 
 
 25 
 
 54 
 
 18 
 
 89 
 
 18 
 
 55 
 
 22 
 
 34 
 
 13 
 
 39 
 
 41 
 
 19 
 
 44 
 
 20 
 
 38 
 
 1916 
 
 • • • • 
 
 107 
 
 18 
 
 62 
 
 21 
 
 45 
 
 14 
 
 90 
 
 18 
 
 51 
 
 20 
 
 39 
 
 15 
 
 17 
 
 18 
 
 11 
 
 25 
 
 6 
 
 11 
 
 1917 
 
 • • • • 
 
 92 
 
 15 
 
 53 
 
 18 
 
 39 
 
 12 
 
 72 
 
 14 
 
 41 
 
 16 
 
 31 
 
 12 
 
 20 
 
 20 
 
 12 
 
 27 
 
 8 
 
 15 
 
 1918 
 
 • • • • 
 
 73 
 
 12 
 
 48 
 
 16 
 
 25 
 
 8 
 
 50 
 
 10 
 
 36 
 
 14 
 
 14 
 
 5 
 
 23 
 
 23 
 
 12 
 
 26 
 
 11 
 
 20 
 
 1919 
 
 • • • • 
 
 60 
 
 8 
 
 36 
 
 10 
 
 24 
 
 7 
 
 50 
 
 8 
 
 28 
 
 9 
 
 22 
 
 7 
 
 10 
 
 10 
 
 8 
 
 17 
 
 2 
 
 4 
 
 1920 
 
 • • • • 
 
 35 
 
 5 
 
 19 
 
 5 
 
 16 
 
 4 
 
 23 
 
 4 
 
 13 
 
 4 
 
 10 
 
 3 
 
 12 
 
 11 
 
 6 
 
 11 
 
 6 
 
 11 
 
 Considering first the total population, it will be noted that beginning with 
 the second year of life with a rate of 10, from the second to the fifth year the 
 mortality is doubled, from the fifth to the tenth year the rate was 26, and from 
 the tenth to the twentieth year 40. The highest mortality fell in the third decade 
 of life with a rate of 56. During the fourth, fifth, and sixth decades, the rates 
 fell by rather even steps, and the sixth decade of life was marked by a mor¬ 
 tality rate of 13. During the seventh decade the rate was more than double 
 that of the sixth, but for the eighth decade it dropped to 19. The rates for 
 
FEBRILE DISEASES 
 
 261 
 
 total whites varied little from those for the total population, except that they 
 were lower between the fifth and ninth years. The rates for the negroes were 
 uniformly higher than those for whites in nearly all age-groups. In regard 
 to the whites, the rates for females were higher than those for males below 
 the tenth year and between the tenth and nineteenth years. In the fourth 
 decade, the male rate was more than three times as high as that for females, 
 and in the fifth decade it was double the female. In the sixth decade the female 
 rate was higher. Above the fifty-ninth year the mortality was considerably 
 higher in males than in females. Among negroes, under the tenth year the 
 rates were higher for females, but between the tenth and twenty-ninth years 
 this was reversed. In the fourth, fifth, and seventh decades the rate for females 
 
 Table 27 .—Number of deaths and rate of death, per 100,000 living inhabitants, from 
 typhoid fever, according to age, color, and sex, for 1910. 
 
 D = death. R = rate. 
 
 
 Total. 
 
 
 
 White. 
 
 
 
 
 
 Colored. 
 
 
 
 Age period. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 Under 1 year. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Between 1 and 2 years 
 
 1 
 
 10 
 
 1 
 
 12 
 
 1 
 
 23 
 
 
 
 
 
 
 
 
 
 2 to 4 years. 
 
 6 
 
 19 
 
 5 
 
 18 
 
 1 
 
 7 
 
 4 
 
 29 
 
 1 
 
 24 
 
 • • • 
 
 • • • 
 
 1 
 
 47 
 
 5 to 9 years. 
 
 13 
 
 26 
 
 8 
 
 19 
 
 4 
 
 18 
 
 4 
 
 19 
 
 5 
 
 78 
 
 2 
 
 65 
 
 3 
 
 89 
 
 Under 10 years. 
 
 20 
 
 20 
 
 14 
 
 16 
 
 6 
 
 13 
 
 8 
 
 18 
 
 6 
 
 46 
 
 2 
 
 32 
 
 4 
 
 59 
 
 10 to 19 years. 
 
 41 
 
 40 
 
 33 
 
 37 
 
 14 
 
 33 
 
 19 
 
 41 
 
 8 
 
 58 
 
 5 
 
 85 
 
 3 
 
 38 
 
 20 to 29 years. 
 
 63 
 
 56 
 
 51 
 
 55 
 
 26 
 
 58 
 
 25 
 
 52 
 
 12 
 
 58 
 
 8 
 
 88 
 
 4 
 
 35 
 
 30 to 39 years. 
 
 40 
 
 45 
 
 32 
 
 44 
 
 24 
 
 67 
 
 8 
 
 21 
 
 8 
 
 51 
 
 3 
 
 39 
 
 5 
 
 61 
 
 40 to 49 years. 
 
 21 
 
 31 
 
 18 
 
 31 
 
 12 
 
 44 
 
 6 
 
 20 
 
 3 
 
 26 
 
 1 
 
 18 
 
 2 
 
 35 
 
 50 to 59 years. 
 
 6 
 
 13 
 
 5 
 
 13 
 
 2 
 
 11 
 
 3 
 
 15 
 
 1 
 
 16 
 
 1 
 
 34 
 
 • • • 
 
 • • • 
 
 60 to 68 years. 
 
 8 
 
 32 
 
 7 
 
 32 
 
 5 
 
 51 
 
 2 
 
 17 
 
 1 
 
 35 
 
 • • • 
 
 • • • 
 
 1 
 
 64 
 
 70 to 79 years. 
 
 2 
 
 19 
 
 2 
 
 21 
 
 1 
 
 25 
 
 1 
 
 18 
 
 
 
 
 
 
 
 80 years and over.... 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 . 
 
 Total . 
 
 201 
 
 36 
 
 162 
 
 34 
 
 90 
 
 39 
 
 72 
 
 29 
 
 39 
 
 46 
 
 20 
 
 51 
 
 19 
 
 42 
 
 was much higher than for males, but in the sixth decade the males had the 
 advantage of a lower rate. 
 
 It was not until after the beginning of the decline of typhoid fever in Balti¬ 
 more that in the annual reports of the health department a gleam of interest 
 in the disease on the part of the authorities can be discovered. In 1875, Com¬ 
 missioner Stuart attributed its prevalence to sewer-gas entering houses from 
 imperfectly trapped cesspools. By 1885, though still clinging to this theory 
 and basing his administrative acts chiefly upon it, he started routine chemical 
 examinations of the waters of the wells and springs, and in a few years had 
 condemned many of these. He also about this time began to question the 
 safety of the general water-supply. By 1890 it was well recognized that the 
 disease was more prevalent in the newly annexed territory, with its water- 
 supply derived almost entirely from wells, that many of the cases in the rest 
 of the city contracted the disease without the city, and that large numbers of 
 
262 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 non-residents suffering with the disease were brought into the city for treat¬ 
 ment. Commissioner McShane established sanitary inspection of the Lake 
 Roland water-supply in 1892, and 4- years later extended it to the Gunpowder 
 watershed. Basing his opinion upon reports of his inspectors, he declared in 
 1896 that the general water-supply was seriously polluted from privies on these 
 sheds. In 1895 a small outbreak was traced to a certain milk-supply. Case 
 reporting, established by law in 1894, had reached some degree of complete¬ 
 ness by 1900. The first study of typhoid fever was undertaken by Dr. C. 
 Hampson Jones in 1899. During the next decade he pointed out that the 
 disease was rather evenly distributed throughout the city, and that, though 
 milk epidemics, infection from polluted wells, contact with previous cases in 
 households, infection out of the city, and spread of the disease by flies all 
 played a part, the great bulk of the cases were infected from the city water- 
 supply. By 1910, thanks to the epidemiological inquiries of Dr. Jones and 
 the investigations of Dr. Stokes, city bacteriologist, and of Dr. W. W. 
 Ford (43), of the department of pathology and bacteriology of the Johns 
 Hopkins University, it was generally recognized that the general water-supply 
 was the chief means by which typhoid fever was spread in Baltimore. 
 
 With the aid of further and more exact data than had hitherto been avail¬ 
 able, the writer (59), inquired into the mode of infection of the cases reported 
 from 1916 to 1919, inclusive. Hot only had the general sanitary conditions 
 materially changed since the date of Dr. Jones’s studies, but in some ways 
 they were constantly improving during the 4 years under consideration. The 
 general results of the investigation, together with those of Assistant Commis¬ 
 sioner of Health Dr. J. F. Hogan, in 1920, are given in table 28. The relatively 
 high proportion of cases certainly, probably, and possibly infected without 
 the city is striking. Most of those of the former division acquired the disease 
 in rural Maryland, but a considerable proportion were infected in other States, 
 notably Virginia, Pennsylvania, Hew Jersey, and Hew York. In some cases 
 the disease was acquired as far away as Maine. In 1916, 14 cases were received 
 from foreign ships. The percentage of infections attributed to recent cases 
 in households and institutions in 1918 and 1919 are probably not far from 
 the usual occurrence in average years, for it would appear from Dr. Jones’s 
 figures for 1904 to 1907, inclusive, based upon less accurate histories, from 
 7 to 9 per cent of the cases could be classed under this category. In the 
 material for 1918, 1919, and 1920, many of these secondary cases occurred in 
 hospitals among patients admitted for other affections, sometimes surgical, 
 who were assigned beds next to those of typhoid patients and were attended 
 by the same nurse. The secondary cases developing in homes were usually in 
 the immediate attendants of the patient. It is probable that the 77 cases traced 
 to milk (infected from actual cases or from proven carriers) in 1916-1917 
 were far short of actual occurrence. These cases all occurred in definite out¬ 
 breaks. 
 
 The absence of recognized milk outbreaks in the last 3 years coincides with 
 the improvement in the supervision of the milk-supply. The category ascribed 
 to proven carriers in households is included among the group of certainly 
 explained, because the evidence was so unusually strong in each instance as 
 to amount to almost to a certainty. Ho cases were attributed to infection 
 from springs, wells, and streams, except where there was definite information 
 
FEBRILE DISEASES 
 
 263 
 
 that they were polluted from the discharges of typhoid patients. From one 
 of the wells to which several cases were attributed, B. typhosus was isolated. 
 Thirteen of the 15 cases ascribed to this mode of infection in 1920 occurred as a 
 sudden outbreak among workers in a large office building in which a tank for 
 flushing closets w r as supplied with water from a sewer pipe draining the over¬ 
 flow from the long-since abandoned Calvert Street city spring. By a cross- 
 connection within the building the water from this tank mixed with that from 
 the city water-supply. Analysis of water from both sources showed a high 
 
 Table 28 .—Modes and sources of infection of typhoid fever, from 1916 to 1920, inclusive. 
 
 
 1916 
 
 1917 
 
 1918 
 
 1919 
 
 1929 
 
 Cases. 
 
 Per cent, 
 of cases. 
 
 Cases. 
 
 Per cent. 
 
 of cases. 
 
 Cases. 
 
 Per cent. 
 
 of cases. 
 
 Cases. 
 
 Per cent. 
 
 of cases. 
 
 Cases. 
 
 Per cent. 
 
 of cases. 
 
 Certainly explained. 
 
 
 
 
 
 
 
 
 
 
 
 Outside of city. 
 
 125 
 
 16 
 
 142 
 
 26 
 
 53 
 
 18 
 
 58 
 
 16 
 
 104 
 
 39 
 
 Contact with recent cases in same house- 
 
 
 
 
 
 
 
 
 
 
 
 hold or institution. 
 
 ? 
 
 9 
 
 21 
 
 4 
 
 39 
 
 13 
 
 42 
 
 12 
 
 16 
 
 4 
 
 Milk epidemics in which source of infec- 
 
 
 
 
 
 
 
 
 
 
 
 tion was demonstrated. 
 
 34 
 
 4 
 
 43 
 
 8 
 
 
 
 
 
 
 
 Springs, wells, and streams within city. 
 
 4 
 
 1 
 
 
 
 
 
 24 
 
 7 
 
 15 
 
 6 
 
 Proven carriers in households or insti- 
 
 
 
 
 
 
 
 
 
 
 tutions. 
 
 14 
 
 2 
 
 2 
 
 • • • 
 
 5 
 
 2 
 
 2 
 
 1 
 
 1 
 
 • • • 
 
 Laboratory infections. 
 
 
 
 
 
 1 
 
 
 2 
 
 1 
 
 
 
 Total . 
 
 177 
 
 23 
 
 208 
 
 38 
 
 98 
 
 32 
 
 128 
 
 36 
 
 130 
 
 49 
 
 Probably explained. 
 
 
 
 
 
 
 
 
 
 
 
 Outside of city. 
 
 » 
 
 9 
 
 9 
 
 9 
 
 16 
 
 5 
 
 32 
 
 9 
 
 12 
 
 4 
 
 Pemote cases in households, carrier not 
 
 
 
 
 
 
 
 
 
 
 
 proven . 
 
 
 9 
 
 13 
 
 2 
 
 22 
 
 7 
 
 27 
 
 8 
 
 6 
 
 2 
 
 Cases in neighborhood. 
 
 9 
 
 9 
 
 • 
 
 9 
 
 9 
 
 9 
 
 9 
 
 7 
 
 2 
 
 3 
 
 1 
 
 Self-infection . 
 
 
 
 4 
 
 1 
 
 4 
 
 1 
 
 
 
 
 
 Total . 
 
 
 
 17 
 
 3 
 
 42 
 
 14 
 
 66 
 
 18 
 
 21 
 
 8 
 
 Possibly explained. 
 
 
 
 
 
 
 
 
 
 
 
 Outside of city. 
 
 ? 
 
 9 
 
 9 
 
 9 
 
 20 
 
 7 
 
 15 
 
 4 
 
 • • • 
 
 • • • 
 
 Total explained . 
 
 177 
 
 23 
 
 225 
 
 41 
 
 160 
 
 53 
 
 209 
 
 58 
 
 151 
 
 57 
 
 Total unexplained . 
 
 597 
 
 77 
 
 319 
 
 59 
 
 142 
 
 47 
 
 149 
 
 42 
 
 116 
 
 43 
 
 Total cases. 
 
 774 
 
 100 
 
 544 
 
 100 
 
 302 
 
 100 
 
 358 
 
 100 
 
 267 
 
 100 
 
 Leaders in columns denote absence of occurrence. Question marks in columns denote 
 absence of information. 
 
 degree of pollution. The outbreak subsided after severance of connection 
 between the two water-supplies. In the one instance of stream infection in¬ 
 cluded, the stream was known to be polluted with sewage from houses harbor¬ 
 ing typhoid fever. Of 20 children who, while on a picnic, drank from this 
 stream, 10 developed fever within 3 weeks. The 3 laboratory infections 
 occurred among medical students who unintentionally sucked into their mouths 
 through pipettes bouillon cultures of B. typhosus. 
 
 It will be noted that the proportion of cases in which the mode of infection 
 was ascertained with certainty, during the 5 years, averaged 35.6 per cent. 
 
264 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 Among the categories in which the mode of infection was ascertained with 
 probability, two deserve some comment. Of the 8 cases included under self- 
 infection, all the persons affected had had the disease before. As they were 
 not in association with active cases, it is not improbable that they were chronic 
 carriers who became infected from themselves. A more interesting group is 
 formed by those who lived in households with individuals who had had typhoid 
 fever from 1 to 30 years before. Of the 68 such persons (including 6 proven 
 carriers), who in 1917 to 1919, inclusive, were suspected of transmitting 
 typhoid fever to members of their households, 66 per cent were females, and 
 this percentage of males to females was approximately the same in each year. 
 The 45 females who were suspected or proven carriers bore relationships as 
 follows to the typhoid-fever patients: Mother, 24; sisters, 12; wives, 3; grand¬ 
 mothers, 2; aunts, 1; domestic servants, 3. The 23 males in question held 
 relationships to the patients as follows : Fathers, 9; brothers, 9; husbands, 3; 
 uncles, 1; unrelated, 1. Not all of the suspected carriers were cultured and 
 not all of the proven carriers can now be separated from the total. Since of 
 the 5 of the latter that can be identified with certainty 4 were females (grand¬ 
 mother, sister, and aunt) and only 1 was a male (father), the proportion as 
 above given would not be materially changed. As the proportion both of the 
 proven and suspected carriers in this list who had relationships in the house¬ 
 holds most likely to be favorable for infecting food is strikingly high, and as 
 for none of the cases, whom they were suspected of infecting, were any other 
 likely sources of infection traceable, it is not improbable that the explanation 
 is valid. 
 
 It was not until 1900 that case reporting was complete enough to yield 
 morbidity rates worthy of serious consideration. It is possible that between 
 1900 and 1915 the errors arising from failure to report cases were largely 
 offset by the practice of including, without careful investigation of the subse¬ 
 quent histories, all suspected cases from whom blood specimens submitted by 
 attending physicians to the bacteriological laboratory gave positive agglutina¬ 
 tion reactions with B. typhosus. With the restricted personnel, it was not 
 possible to follow each case in detail and to clear the records of cases reported 
 on evidently mistaken diagnosis. 
 
 Before 1917, cases among non-residents from rural Maryland were included 
 among the Baltimore cases; from this date they were not so included, but 
 through the State Board of Health were officially transferred to the lists of the 
 counties of origin. Some cases among residents, who, after contracting the 
 disease in the counties, were brought to the city, also fell into this category. 
 Cases in non-residents from other States, including the not inconsiderable 
 number of cases removed from ships, and in residents who contracted the 
 disease in other States, have always been included in the official lists of Balti¬ 
 more cases. With fuller histories and more intensive oversight of cases than 
 had hitherto been practicable, it was possible after 1915 to secure more accurate 
 morbidity data. Therefore, for the 5-year period 1916-1920, it may be said 
 that the number of reported cases of typhoid fever included in the official lists 
 represents with a fair degree of certainty the actual occurrence of cases which 
 under the regulations should be so listed. These figures do not, however, repre¬ 
 sent the true morbidity of local origin, for in these 5 years, on an average, 25 
 per cent of the cases were certainly infected without the city. Taking the 
 
FEBRILE DISEASES 
 
 265 
 
 figures as they stand, the course of morbidity (table 29), though irregular, rose, 
 on the whole, between 1900 and 1910. During this period the rates rose from 
 172 to 330, or nearly doubled. For the first 5 years (from 1900 to 1904) the 
 curves of the morbidity and mortality rates rose and fell together. During 
 the next 2 years the former rose and the latter fell. In 1907 the two rates 
 rose together, but in 1908, while the morbidity rate remained stationary, the 
 
 Table 29. —Morbidity rate, per 100,000 living inhabitants, and the percentage of case 
 
 fatality for typhoid fever, from 1900 to 1919, inclusive. 
 
 C = cases. R = rate. 
 
 Year. 
 
 Morbidity. 
 
 Deaths. 
 
 Per cent, 
 case fa¬ 
 tality. 
 
 Year. 
 
 Morbidity. 
 
 Deaths. j 
 
 Per cent. 
 
 case fa¬ 
 
 tality. 
 
 Year. 
 
 Morbidity. 
 
 Deaths. 
 
 Per cent. 
 
 case fa¬ 
 
 tality. 
 
 C 
 
 R 
 
 C 
 
 R 
 
 C 
 
 R 
 
 1900.. 
 
 871 
 
 172 
 
 189 
 
 22 
 
 1908.. 
 
 1426 
 
 255 
 
 180 
 
 13 
 
 1916.. 
 
 776 
 
 128 
 
 107 
 
 14 
 
 1901.. 
 
 792 
 
 154 
 
 141 
 
 18 
 
 1909.. 
 
 1069 
 
 189 
 
 136 
 
 13 
 
 1917.. 
 
 544 
 
 89 
 
 92 
 
 17 
 
 1902.. 
 
 1086 
 
 209 
 
 220 
 
 20 
 
 1910.. 
 
 1891 
 
 330 
 
 235 
 
 12 
 
 1918.. 
 
 302 
 
 49 
 
 73 
 
 24 
 
 1903.. 
 
 768 
 
 146 
 
 189 
 
 25 
 
 1911.. 
 
 1201 
 
 208 
 
 154 
 
 13 
 
 1919.. 
 
 359 
 
 50 
 
 60 
 
 17 
 
 1904.. 
 
 916 
 
 172 
 
 199 
 
 22 
 
 1912.. 
 
 1083 
 
 185 
 
 136 
 
 13 
 
 1920.. 
 
 267 
 
 36 
 
 35 
 
 13 
 
 1905.. 
 
 1019 
 
 188 
 
 197 
 
 19 
 
 1913.. 
 
 1163 
 
 197 
 
 135 
 
 12 
 
 
 
 
 
 
 1906.. 
 
 1215 
 
 222 
 
 183 
 
 15 
 
 1914.. 
 
 757 
 
 127 
 
 130 
 
 17 
 
 Aver.. 
 
 946 
 
 168 
 
 150 
 
 16 
 
 1907.. 
 
 1417 
 
 256 
 
 230 
 
 16 
 
 1915.. 
 
 949 
 
 158 
 
 128 
 
 13 
 
 
 
 
 
 
 mortality rate fell. They rose simultaneously to a peak in 1910. In all except 
 3 of the 11 years the curves for morbidity and mortality rose and fell together. 
 In the remaining 10 years of the period the morbidity rates fell from 330 to 
 36, a decrease of 89 per cent. The fall was not continuous, however, for in 
 1913, 1915, and 1919 there were reactions, that in 1915 being considerable. 
 
 Table 30. —Rate of morbidity, per 100,000 living in¬ 
 habitants, for typhoid fever by color and sex for 
 1918 and 1919. 
 
 Year. 
 
 Total. 
 
 White. 
 
 Colored. 
 
 Total. 
 
 Male. 
 
 Fern. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 1918 . 
 
 46 
 
 47 
 
 61 
 
 34 
 
 39 
 
 29 
 
 48 
 
 1919 . 
 
 44 
 
 46 
 
 51 
 
 41 
 
 36 
 
 41 
 
 25 
 
 Average ... 
 
 45 
 
 46 
 
 56 
 
 37 
 
 37 
 
 35 
 
 36 
 
 The slight reaction in 1919 was associated with the annexation of that year, 
 when the rate in the annexed territory was much higher than in the old city. 
 
 The rates for whites and negroes and for males and females, data for which 
 are available only for 1918 and 1919, are given in table 30. If the figures for 
 these two years may be taken as representative, the incidence of the disease is 
 greater in the white race than in the colored, greatest in white males, and 
 greater in white females than in either colored males or females. 
 
266 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 As the value of case-fatality rates is so intimately dependent upon the 
 accuracy of morbidity and mortality figures, it is necessary in considering them 
 to bear in mind the explanations already given of these. Particularly impor¬ 
 tant is it to recall that while deaths of all non-residents have been continuously 
 recorded in the city tables of mortality since 1916, the cases among non¬ 
 residents of rural Maryland brought to Baltimore have been excluded from 
 the morbidity lists. Therefore, for the five years between 1916 and 1920, the 
 case-fatality rates are not directly comparable with those of previous years. 
 In table 29 the case-fatality rates in percentages are given from 1900 to 1920. 
 In this period they fluctuate rather widely, between 25 per cent, the highest, 
 and 12 per cent, the lowest. In 11 of the 21 years they were over 15 per cent; 
 the lowest rate, 12 per cent, was recorded in two years, rates of 13 per cent, in 
 six years, and of 14 and 15 per cent in 1 year. With the exception of 1918, 
 when in October a number of individuals with typhoid fever died with influenza, 
 rates of 18 per cent or over occurred only during the first 6 years of this 
 
 Table 31. — Case-fatality rates for typhoid fever, according to 
 color and sex, for the old wards of Baltimore, for 1919. 
 
 
 Mortality. 
 
 Morbidity. 
 
 Percentage 
 
 case 
 
 fatality. 
 
 Total males . 
 
 27 
 
 159 
 
 17 
 
 Total females. 
 
 17 
 
 134 
 
 13 
 
 Total white . 
 
 35 
 
 259 
 
 14 
 
 White males . 
 
 20 
 
 139 
 
 14 
 
 White females . 
 
 15 
 
 120 
 
 13 
 
 Total colored . 
 
 9 
 
 34 
 
 26 
 
 Colored males . 
 
 7 
 
 20 
 
 35 
 
 Colored females . 
 
 2 
 
 14 
 
 14 
 
 Total . 
 
 44 
 
 293 
 
 15 
 
 period. It will be noted that the 6 years, 1908 through 1913, stand out as an 
 unbroken period of exceptionally low rates. A rise in the rates to 17 per cent 
 in 1914 was followed by a fall to 13 per cent and 14 per cent in 1915 and 
 1916, respectively. High rates in the next 2 years were succeeded by a return 
 to 13 per cent in 1920. However, when the rates from 1917 to 1920 are 
 adjusted to the basis of previous years by the addition to the divisors (i. e., the 
 reported cases) of those cases from rural Maryland which were transferred to 
 their places of origin, or, what amounts to the same thing, by the subtraction 
 from the dividends of the deaths occurring among them, the rates are 13 per 
 cent, 18 per cent, 15 per cent, and 13 per cent instead of the higher official 
 figures given in the table. It would appear, therefore, that if case reporting be 
 considered as fairly accurate since 1906, the normal range of case fatality in 
 Baltimore varies from 12 per cent to 18 per cent, with an average of 14 per cent. 
 
 Accurate data for determining the influence of sex and color upon the 
 fatality rates of typhoid fever are limited to 1919. These are analyzed in 
 table 31. Owing to the smallness of the figures for some categories and the lack 
 of correction for age, some of the percentages are perhaps subject to con- 
 
FEBRILE DISEASES 
 
 267 
 
 siderable probable error. Taken at their face value, the risk rate of dying 
 of clinically recognized typhoid fever was twice as great for colored as for 
 white, somewhat greater for white males than for white females, over twice 
 as great for colored males than for colored females, and a fourth greater for 
 total males than for total females. 
 
 Whereas it would appear that the greatest incidence of typhoid fever in 
 Baltimore has been in the summer and autumn, in many years between 1856 
 and 1881 the number of deaths in the winter months, December, January, 
 and February, equaled or even exceeded that for the warm months. Since 1881 
 the bulk of the deaths have fallen in the summer and autumn. Since case 
 reporting was instituted the cases have shown the same seasonal distribution. 
 The four years 1915-1919 (table 32) may fairly illustrate the average seasonal 
 distribution of deaths. The deaths lag about one month behind the reported 
 
 Table 32 . — Number of deaths by months and monthly annual mortality rate, per 
 100,000 living inhabitants, from typhoid fever, from 1915 to 1919, inclusive. 
 
 D = death. R = rate. 
 
 
 1915 
 
 1916 
 
 1917 
 
 1918 
 
 1919 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 Jan. 
 
 11 
 
 22 
 
 8 
 
 16 
 
 7 
 
 13 
 
 2 
 
 4 
 
 4 
 
 7 
 
 Feb. 
 
 7 
 
 15 
 
 4 
 
 9 
 
 3 
 
 6 
 
 3 
 
 6 
 
 5 
 
 9 
 
 Mar. ... 
 
 5 
 
 10 
 
 2 
 
 4 
 
 4 
 
 8 
 
 2 
 
 4 
 
 4 
 
 7 
 
 Apr. 
 
 6 
 
 12 
 
 4 
 
 8 
 
 8 
 
 16 
 
 7 
 
 14 
 
 • • • 
 
 • • • 
 
 May .... 
 
 4 
 
 8 
 
 3 
 
 6 
 
 7 
 
 13 
 
 3 
 
 6 
 
 8 
 
 13 
 
 June ... 
 
 9 
 
 18 
 
 7 
 
 14 
 
 3 
 
 6 
 
 2 
 
 4 
 
 4 
 
 7 
 
 July .... 
 
 14 
 
 27 
 
 14 
 
 27 
 
 6 
 
 12 
 
 5 
 
 10 
 
 3 
 
 5 
 
 Aug. ... 
 
 14 
 
 27 
 
 11 
 
 21 
 
 13 
 
 25 
 
 14 
 
 27 
 
 8 
 
 13 
 
 Sept. ... 
 
 22 
 
 45 
 
 20 
 
 40 
 
 13 
 
 26 
 
 11 
 
 22 
 
 9 
 
 15 
 
 Oct. 
 
 12 
 
 23 
 
 21 
 
 41 
 
 14 
 
 27 
 
 17 
 
 32 
 
 5 
 
 8 
 
 Nov. 
 
 17 
 
 34 
 
 10 
 
 20 
 
 9 
 
 18 
 
 1 
 
 2 
 
 6 
 
 10 
 
 Dec. 
 
 7 
 
 14 
 
 3 
 
 6 
 
 5 
 
 10 
 
 6 
 
 11 
 
 4 
 
 7 
 
 Total . 
 
 128 
 
 21 
 
 107 
 
 18 
 
 92 
 
 15 
 
 73 
 
 12 
 
 60 
 
 8 
 
 cases, but follow the same general course. For cases, with February usually as 
 the month of lowest incidence, there is a gradual progression of the disease until 
 July, when there is a rapid rise culminating in a peak usually about the middle 
 of September, or more rarely the last of August or even early in October. 
 The decline is usually very abrupt during the first month after the peak, and 
 then more gradual to the end of the cycle. 
 
 Administrative measures directed particularly to the control of typhoid 
 fever developed very gradually. As early as 1888, wells to which certain cases 
 were traced were closed, and a few years later from time to time several local 
 epidemics traced to milk were controlled by shutting off the contaminated 
 milk-supplies. It was not until 1912, however, that measures were taken 
 routinely to prevent the entrance into the city of milk from farms harboring 
 cases of typhoid fever and to guard milk within the city from infection from 
 cases on the premises of milk handlers and of the general public. Investiga¬ 
 tions conducted in 1916 and 1917 showed that in spite of these barriers 
 18 
 
268 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 numbers of small milk epidemics occurred. Only since 1916 have cultures 
 been made of suspected carriers on dairy farms, among milk and other food 
 handlers, and in households and institutions, and control exercised over proven 
 carriers. It was not until 1916 that printed instructions giving in detail the 
 precautionary measures to be taken to prevent the spread of typhoid fever 
 were delivered to households and institutions with patients with this disease, 
 and attempts made to enforce them through the health wardens and nurses. 
 Since this date special efforts have been made to have patients from crowded 
 households removed to hospitals. Since its introduction the health department 
 has systematically urged the use of protective inoculation, and has required it 
 of attendants in hospitals receiving typhoid fever patients. The response on 
 the part of the general public has not been encouraging, and the decrease in 
 the incidence of the disease of late years can not be credited in any large degree 
 to this method of protection. Whereas no exact quantitative valuation can be 
 set upon them, there is a large body of evidence supporting the inference that 
 restrictive measures imposed on the acts of persons by the health department 
 and by physicians have very materially decreased the spread of typhoid fever 
 in the community during the last decade. 
 
 SUMMARY. 
 
 When the curve for the annual rates for the acute intestinal diseases as a 
 whole is viewed for the entire period, several distinct waves of mortality stand 
 out clearly. (Table 19, graph 8.) The first, beginning at some unknown time 
 previous to 1812 and characterized by rates fluctuating between 297 in 1814 
 and 664 in 1818, ended in 1827 with the comparatively low rate of 181. The 
 second wave, starting in 1828, reached its peak in 1832 with the remarkably 
 high rate of 1,412 and receded very brokenly to its low point in 1839 with a 
 rate of 162. But for the influence of the cholera epidemics of 1832 and 1834, 
 the rates in these years would have stood at 486 and 340 instead of 1,412 and 
 412, respectively. However, as it is certain that a considerable number of deaths 
 from cholera were attributed to cholera infantum and to cholera morbus and 
 cramp colic, it is evident that cholera exercised an influence upon the high 
 rates for these two years even greater than is shown by the official figures. It is 
 equally clear, however, that before the advent of cholera the rates were tending 
 to higher levels during the first few years of this period. The third wave, not 
 only short but relatively low, reached its peak in 1842 with a rate of 252. 
 By 1845 it had subsided to 167. The fourth wave, characterized by excessively 
 high rates, began in 1846 and ended in 1865. The rise in the rates to a peak 
 of 659 in 1854 was gradual, but somewhat irregular. The fall to the end of 
 the wave, with a rate of 342 was almost uninterrupted. This wave was asso¬ 
 ciated with a rise in the rates for every one of the separate causes, including 
 cholera. The latter disease, though hidden under other rubrics, contributed 
 in no small degree to the high rates of 1849 and 1854 and perhaps other years. 
 Coincident with the return of cholera in 1866, a fifth wave began, reached a 
 peak in 1874 with a rate of 528, and subsided in 1878, when the rate stood at 
 264. A sixth wave, beginning in 1879 and running an irregular course, attained 
 its peak in 1890 with a rate of 390 and subsided in 1903, when the rate fell 
 to 162. After an interval of 64 years, the rate now stood at the same level as 
 
FEBRILE DISEASES 
 
 269 
 
 in 1839. The seventh and last wave, which began in 1904, is still in progress. 
 It is characterized by relatively low and, on the whole, constantly descending 
 rates, which during the last 5 years have shown a tendency to stabilize around 
 a comparatively low level. During the whole period, with the exception of 
 a few years, the slope of the curve has been determined chiefly by cholera 
 infantum, which, but for cholera and for diarrhoea in occasional years, has 
 been the chief contributor. 
 
 The course of mortality for the group as a whole in relation to that for its 
 various members may be studied conveniently in the curves for the rates as 
 averaged for 5-year periods. (Table 20, graph 9.) For more accurate com-, 
 parison, the rates for cholera infantum and diarrhoea are given in combina¬ 
 tion as well as separately. It will be observed that beginning with a rate of 
 406 for the 4 years ending in 1815, the whole rate stood at 462 in 1816-1820, 
 413 in. 1821-1825, and 242 in 1826-1830. The averaged rates for each of the 
 separate rubrics, cholera infantum, diarrhoea (and for these two combined), 
 and typhoid fever, all rose and fell with the total rate. For the 5-year period 
 ending in 1835, this favorable course was reversed and the total rate rose to 517. 
 This change was associated w r ith a stationary state for the rate for diarrhoea 
 and a fall in that for typhoid fever and a relatively slight rise in that for 
 dysentery. The rate for cholera infantum rose sharply. The determining cause 
 for this notable rise in the total rate was the entry of a new element, Asiatic 
 cholera, in 1832 and 1834. But for these events the elevation of the total rate 
 for this 5-year period would have been relatively slight, i. e., only 75, when 
 the averaged rates of 200 due to cholera are subtracted from the total rates. 
 Concurrent with the declines in rates for each separate rubric, except the 
 negligible typhoid rate, there was a sharp fall to 202 in the total rate for the 
 5 years ending in 1840. In 1845 the combined rate stood practically unchanged 
 at 208. Since 1825, therefore, it had declined by approximately 50 per cent. 
 This striking change was due to declines in the rates for cholera infantum, 
 diarrhoea, and dysentery, and of the absence of cholera between 1835 and 1840. 
 In other words, this result was brought about by declines during the 20-year 
 period, 1826-1845, in the rates for the indigenous members of the group. 
 The total rate was not destined again to attain so low a level until 1905. 
 
 That this fall in the rates was not due to failure to register deaths is 
 proven by the fact that Joynes, Wynne, and Frick, who made careful statistical 
 studies of the Baltimore material of this time, accepted the official figures of 
 the total number of deaths as substantially correct and by the evidence that 
 the decline in the rates for this particular group of diseases coincided with a 
 similar decline in the death-rates for all causes. In the 5-year period ending 
 in 1850, the whole situation changed. Due to corresponding changes in the 
 rates for cholera infantum, diarrhoea, dysentery, and typhoid fever, the total 
 rate rose to 357. By 1855 it had surpassed any previous high level and stood 
 at 534. This time, in addition to rises for the three usually responsible rubrics, 
 typhoid fever, hitherto unimportant, achieved a rate of 58, and cholera, 
 present in 1854 in a form much more fatal than was officially recognized, added 
 materially to the toll of death from these diseases. For the 5 years ending in 
 1860, as the result of the absence of cholera and decline in the rates for diar¬ 
 rhoea, dysentery, and typhoid fever, the total rate fell to 475. Cholera infantum 
 rose, however, to 300, the highest level yet recorded. A further decline in 
 
270 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 the total rate to 373 in 1861-1865 was owing mainly to a sharp drop in the 
 rates for cholera infantum and for dysentery; typhoid fever rose conspicuously. 
 This improvement in the total rate was but temporary, for, turning upward, 
 it registered 436 in 1866-1870. This change, while influenced to some degree 
 by a small outbreak of cholera in 1866, was brought about chiefly by increases 
 in the rates for cholera infantum, diarrhoea, dysentery, and typhoid fever. 
 The rate for the latter had now reached the highest point recorded in its 
 history. With slight declines in other rubrics and a sharp rise in cholera 
 infantum, the total rate stood at 457 in 1871-1875. With recessions for every 
 rubric, the total rates declined to 346 in 1876-1880 and 316 in 1881-1885. 
 
 During the 40 years between 1846 and 1885 there was, then, a very conspicu¬ 
 ous change in the curve for the acute intestinal diseases, resulting in a wave 
 with two sharp crests, the first in 1860 and the second in 1875. This change 
 was brought about during the first crest in part by two relatively moderate 
 visitations of cholera (1849 and 1854), but mainly by unusual fatality from 
 dysentery, cholera infantum, diarrhoea, and typhoid fever, and during the 
 second crest by high rates for all the other members of the group save dysentery 
 and cholera. The decline in the total rate between these two crests, which 
 reached its lowest point during the Civil War, was due to a fall in the rates for 
 cholera infantum and dysentery and to the absence of cholera. Cholera played 
 no conspicuous role after 1866. The influence of the decline in the rates 
 for cholera infantum, dysentery, and typhoid fever upon the total rate after 
 1875 is very evident. The ascent in the total rate to 359 during the 5-year 
 period ending in 1886-1890 was due to sharp rises in the rates for dysentery 
 and diarrhoea. Cholera infantum remained stationary, and typhoid fever con¬ 
 tinued its gradual decline. During the 25 years between 1891 and 1915 the 
 total rate fell uninterruptedly from 359 to 131, but the rate of decline was 
 much less acute during the first three than during the last two quinquennia of 
 the period. After 1900, dysentery ceased to be a factor of importance and 
 typhoid fever continued to fall. But for an upward turn between 1901 and 
 1905, the decline in the rate for cholera infantum was continuous. Diarrhoea, 
 after rising slightly between 1891 and 1895, had fallen to a relatively low 
 level by 1905. The rates for these two rubrics taken together fell continuously 
 between 1891 and 1915. There was no fall in the total rate for the 5 years 
 ending in 1920. The considerable fall for typhoid fever was counterbalanced 
 by slight reactions in the rates for the other rubrics. 
 
 To what degree may the courses of these diseases be explained by changes in 
 environment and population and by improvements in medical care and admin¬ 
 istrative efforts of a special character on the part of the health department ? In 
 the history of the water-supply it has been pointed out that the drinking-water 
 has been subject to pollution from the earliest times: The intra-urban supply 
 from springs and wells, the main dependence of the major part of the popula¬ 
 tion until after 1850, must have been seriously polluted from the earliest days. 
 Contamination was doubtless to some degree lessened for a time at least after 
 the enforcement of the ordinances of 1817 and 1820 requiring the abandonment 
 of privies in certain localities and the water-tight construction of cesspools 
 near springs and wells. That these measures were not thoroughly protective 
 seems certain, for the evidence at hand indicates that cholera was commonly if 
 not invariably spread by the internal water-supply, and that the cesspools were 
 
FEBRILE DISEASES 
 
 271 
 
 constantly overflowing. With the rapid increase in the population, particularly 
 between 1800 and 1830 and between 1846 and 1855, the pollution of the springs 
 and w 7 ells must have grown rapidly worse. Many were closed by administrative 
 authority between 1870 and 1900, and after the latter date but few remained. 
 
 The external water-supply, available to only a small proportion of the popu¬ 
 lation when introduced in 1808, served perhaps one-third of the people by 1825 
 and at most one-half by 1850. It is improbable that it was seriously polluted 
 before 1845 or 1850. From this date until 1881, when the Gunpowder supply 
 became the chief source, the pollution must have been very grave. This latter 
 supply, which became progressively the subject of contamination from the 
 increase in the village and farming population on its tributaries, was improved 
 to a considerable degree by storage in the numerous reservoirs in the city. 
 Until 1915 water from the heavily polluted Jones Falls-Lake Roland water¬ 
 shed was mixed with it. By 1895 both water-sheds were so contaminated that 
 sanitary inspectors were employed to guard them. There is abundant evidence 
 that between 1845 and 1911, w r hen chlorinization was introduced, either part 
 or all of the external water-supply was subject to serious pollution with excreta 
 of man and domestic animals. Chlorinization since 1911 and filtration and 
 chlorinization, together with the abandonment of the Lake Roland supply 
 since 1915 and the partial abatement of nuisances on the Gunpowder watershed, 
 have greatly reduced but not entirely offset the dangers of pollution of the 
 drinking-water. It is probable that since 1919, at least, it has been at most 
 times free from micro-organisms responsible for the acute intestinal affections. 
 Highly important in connection with the pollution of the external water-supply 
 is the circumstance that it has never been subject to contamination from the 
 intestinal discharges of large communities of human beings. The complete 
 absence of large towns and of cities on the water-sheds has doubtless meant 
 much in this regard. With the exception of Towson, a town of 1,000 inhabitants 
 on the Lake Roland watershed, the pollution of the external water-supply with 
 human excreta has been limited to that derived from a relatively thinly settled 
 countryside dotted with occasional villages. While the pollution from these 
 sources has been far from negligible and has increased markedly in recent years, 
 it has never been comparable in degree with that obtaining in connection with 
 the watersheds of many American and foreign cities. Had there been large 
 urban communities discharging sewage into the sources of the Jones Falls and 
 in later years into those of the Lake Roland and Gunpowder watersheds, Balti¬ 
 more could hardly have escaped so lightly from cholera, and the rates from 
 typhoid fever, dysentery, and diarrhoea must have been notably higher than 
 those experienced. From the consideration of nuisances connected with imper¬ 
 fect drainage, privies, cesspools, lack of proper paving, and defective methods 
 of removal and disposal of garbage and manure, it is evident that, until very 
 recent years, conditions were most favorable for the spread of this group of 
 diseases by pollution of the intraurban water-supply and of milk and by flies 
 and other insects. With the gradual abandonment of wells and springs within 
 the city between 1870 and 1900, the danger from privies and cesspools was 
 practically limited to the possibilities of spread of infection by flies, and great 
 as were the esthetic benefits of the new sewage system, its actual sanitary 
 influence when brought into service between 1912 and 1918 was much less 
 marked than would have been the case at an earlier date. As a result of the 
 
272 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 marked general improvement in municipal housekeeping during the last 20 
 years, and particularly since 1910, the danger from fly infection has greatly 
 decreased. 
 
 In the discussions of the milk-supply it has been made clear that, before 
 administrative efforts at its control were begun in 1894, a large proportion of 
 the milk was deficient in quality and exposed constantly to numerous opportuni¬ 
 ties for contamination. Until the ice-supply was increased and cheapened 
 through improvements in transportation and storage, and artificial ice became 
 available, much of the milk was either not refrigerated at all or, at least, very 
 defectively. The administrative reforms begun in 1894 showed results almost 
 immediately in the great improved food value of milk and in the cutting down 
 to some degree of the possibilities of contamination from impure water and 
 from flies. In spite of laws and of persistent and well-directed administrative 
 efforts, as late as 1917 the general sanitary conditions under which the bulk of 
 the milk was handled were deplorable and the opportunities for contamination 
 were endless. Until this date milk-borne outbreaks of typhoid fever were com¬ 
 mon, and with the notable exception of the Walker-Gordon Laboratory and of 
 a few dealers who in recent years pasteurized with care, the milk-supply was 
 doubtless often infected with the causal agents of dysentery and diarrhoea as 
 well. Whatever dangers may be incident to high bacterial content were almost 
 constant attributes of the bulk of the milk until the fall of 1918. 
 
 Of other foods likely to be infected outside the city, the fresh vegetables 
 commonly eaten raw, such as lettuce, celery, radishes, cabbage for slaw, and the 
 like, and fruits like strawberries, were perhaps not infrequently contaminated 
 from city night-soil so generally used as fertilizer by neighboring farmers. 
 Danger from this source persisted until 1917. 
 
 While the great oyster-beds of the lower Chesapeake have always been reason¬ 
 ably safe from sewage contamination, opportunity for the spread of typhoid 
 fever and perhaps of dysentery and diarrhoea by infected oysters has existed 
 from the earliest times until recent years. In earlier years productive oyster- 
 beds were near enough to the city to be contaminated from the sewage-polluted 
 waters of the city streams and the basin, but a more serious menace in this 
 regard was due to the custom, proscribed only in the last few years, of fattening 
 oysters in polluted waters off the towns below the city. 
 
 The imperfect methods of collection and disposal of garbage, slaughter and 
 packing house refuse, night-soil, and stable manure which obtained until the 
 last few years resulted in the presence in houses, cellars, yards, courts, alleys, 
 streets, streams, and the basin of an abundance of organic matter to attract 
 and to feed the swarms of flies bred in the numerous stables within the city. 
 
 When the growth-rates of the population expressed in percentages of increase 
 and the averaged death-rates from this group of diseases are compared (table 
 33) over decennial periods, a very definite correlation is evident. The very high 
 death-rate for the decennium ending in 1820 followed growth increases of 76 
 per cent between 1801 and 1810 and of 35 per cent between 1811 and 1820. 
 A decided decline in the death-rate by 1830 coincided with a continued fall 
 in the rate of population increase. The practically stationary state of the rate 
 of population increase between 1831 and 1840 was accompanied by a relatively 
 slight increase in the death-rate in 1840 and a fall in 1850 to the lowest level 
 recorded until 1900. But for the occurrence of epidemic cholera in 1832 and 
 
FEBRILE DISEASES 
 
 273 
 
 1834, the death-rate for the period ending in 1840 would have shown a decided 
 drop. It is clear, then, that, so far as the indigenous diseases of this group are 
 concerned, in a period of diminishing immigration following a period of very 
 high immigration-rates, the death-rates fell significantly from a very high to 
 a relatively low level. But between 1841 and 1850 the rate of population 
 increase jumped to 65 per cent and was reflected in 1860 by an increase in 
 the death-rate by 80 per cent over 1850. With the decline in the percentages 
 of population increase to 26 for the decennia ending in 1860 and in 1870 and 
 24 for that ending in 1880, the death-rates fell by 20 per cent in 1870, remained 
 stationary in the next decade, and declined considerably between 1881 and 1890 
 in the face of a slight increase in the rate of population growth during this 
 last period. From 1891 to 1910 the rates for mortality and for population 
 growth fell steadily together. With a slight rise in the rate of population 
 growth between 1911 and 1920, the fall in the death-rate was less acute than 
 in the previous decennium. The close correspondence between these fluctuations 
 
 Table 33. —Percentage of population increase between census counts contrasted with 
 average rates of deaths, per 100,000 living inhabitants, by 10-year periods from 
 acute intestinal diseases, from 1800 to 1920, inclusive. 
 
 Periods. 
 
 Per cent, of 
 population in¬ 
 crease between 
 census counts. 
 
 Average rates 
 of death from 
 acute intestinal 
 diseases by 
 10-year periods. 
 
 Periods. 
 
 Per cent, of 
 population in¬ 
 crease between 
 census counts. 
 
 Average rates 
 of death from 
 acuteintestinal 
 diseases by 
 10-year periods. 
 
 1801-1810_ 
 
 76 
 
 • • • 
 
 1861-1870_ 
 
 26 
 
 404* 
 
 1811-1820_ 
 
 35 
 
 437 
 
 1871-1880_ 
 
 24 
 
 402 
 
 1821-1830_ 
 
 29 
 
 328 
 
 1881-1890_ 
 
 31 
 
 338 
 
 1831-1840.... 
 
 27 
 
 360* 
 
 1891-1900_ 
 
 17 
 
 278 
 
 1841-1850_ 
 
 65 
 
 280 
 
 1901-1910_ 
 
 10 
 
 182 
 
 1851-1860_ 
 
 26 
 
 505* 
 
 1911-1920_ 
 
 14 
 
 131 
 
 * Periods during which there occurred epidemics of cholera. 
 
 in rates of population growth and the death-rates from this group of diseases 
 finds a ready explanation in the recorded history of the general sanitation of 
 the city. The periods of rapid growth were marked by overcrowding and by a 
 multiplication of nuisances of all types, but especially of those connected with 
 the pollution first of the internal and then of the external water-supply. A 
 considerable period elapsed before the ill effects of the great migration 1846 to 
 1855 could be even partially adjusted by construction and administration, and 
 the sanitary habits of the newcomers, many of whom had been accustomed to 
 live in cellars or hovels, had approached the level of those of the older citizen¬ 
 ship. Any considerable degree of slackening of immigration would, on the other 
 hand, exercise a salutary effect. 
 
 As foreign immigrants have higher birth-rates than the native-born, and as 
 high birth-rates result in a larger proportion in the population of those most 
 susceptible to acute intestinal affections, it is to be supposed that high immigra¬ 
 tion-rates, such as occurred between 1846 and 1855, would be followed by a 
 period of high death-rates from these diseases, and notably from cholera infan¬ 
 tum. As according to the figures of Frick in 1850, the mortality-rates for 
 cholera infantum were more than double and those for dysentery were more 
 
274 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 than four times greater in whites than in negroes, and, as in 1919, typhoid fever 
 was more than twice as fatal for negroes as for whites, it may be concluded 
 that a large proportion of negroes has exerted a favorable effect upon the 
 death-rates for the former and an unfavorbale effect upon those for the latter. 
 There can be little doubt that the fall in the rates since 1880 have been due to 
 some degree to the habit of a large proportion of the foreign immigrant women 
 entering after that date to nurse their babies. It is certain that typhoid fever 
 and dysentery were introduced on a large scale by foreign immigrants in the 
 middle of the last century. Indeed, the epidemic outbreak of dysentery at 
 that time is probably to be laid at their door. There is reason to suppose that 
 these diseases spread to the civil population from the large number of cases 
 brought to the large military hospitals established in the city during the 
 Civil War. It has been established that not only have many cases of typhoid 
 fever been brought into the city for treatment from rural Maryland and by 
 foreign and coastwise shipping, but that many citizens have acquired both 
 typhoid fever and dysentery while on visits elsewhere. It has been shown that 
 the health department has never undertaken the sanitary control of persons 
 with dysentery, diarrhoea, and cholera infantum, and that measures of this 
 nature were first applied to cholera in 1866 and to typhoid fever in 1916. 
 While a favorable outcome in dysentery and diarrhoea have undoubtedly been 
 determined by medical treatment since the earliest days, it is doubtful if 
 medical care influenced the death-rate from cholera, or, if before 1885 or 1890, 
 the fate of individuals with cholera infantum or typhoid fever was on the 
 whole very materially affected by the ministrations of the average physician 
 or hospital. Beyond question, since 1890 most of the decline in the death-rate 
 from cholera infantum and much of that from typhoid fever, and to a con¬ 
 siderable degree the decrease in the incidence of both, are to be ascribed to 
 the actions of medical men. 
 
Chapter XI. —Typically Contactive Diseases. 
 
 1. Acute exanthematous diseases: Small-pox; Cowpox; Chicken-pox; 
 
 Scarlet fever; Measles; Influenza. (Tables 34 to 59, graphs 11 to 16.) 
 
 2. Acute inflammatory affections of the respiratory tract: Whooping- 
 cough; Diphtheria; Pneumonia. (Tables 60 to 77, graphs 17 to 20.) 
 
 3. Tuberculosis. (Tables 78 to 90, graphs 21 to 26.) 
 
 THE EXANTHEMATOUS DISEASES, OR THOSE ACUTE 
 FEBRILE COMMUNICABLE DISEASES CHARACTER¬ 
 IZED BY ERUPTIONS OF THE SKIN AND 
 CERTAIN MUCOUS MEMBRANES. 
 
 The diseases of this class which have been recognized in the statistical nos¬ 
 ology of the Baltimore health department are variola or small-pox, vaccinia or 
 cow-pox, varicella or chicken-pox, morbilli or measles, scarlatina or scarlet 
 fever, and influenza. The members of this group of diseases have in common 
 many characteristics. These concern especially the seats and characters of their 
 principal lesions, their mode of spread, their seasonal distribution, their 
 reaction upon the community, their age incidence, and to a certain degree their 
 causation and their immunity relations. They are all marked by cutaneous 
 eruptions symmetrically distributed, and which for three (small-pox, chicken- 
 pox, and vaccinia, especially when generalized) are so alike in appearance and 
 anatomical changes that in many respects they can be differentiated only after 
 close study. The early eruption of small-pox, and especially in the severe cases 
 in which death occurs early in the disease, closely resembles those of measles 
 and scarlet fever, and the latter two were until comparatively recent times 
 confused with each other and with small-pox. 
 
 The cutaneous eruptions of measles, scarlet fever, and influenza, though 
 widely different from the more marked inflammatory lesions of small-pox and 
 chicken-pox, are among themselves of the same general character, and, except 
 for certain peculiarities of surface distribution and arrangement, often so 
 alike as to give rise to confusion in diagnosis. 
 
 In all of them which occur under natural conditions in man, there is con¬ 
 junctivitis, usually slight but sometimes severe, which may extend to the inner 
 structures of the eye. It is a well-established fact that any of them except 
 vaccinia and chicken-pox may occur without recognized cutaneous lesions. 
 It is quite true that the cutaneous eruption of influenza is often absent and is 
 not clearly characteristic, as are the cutaneous lesions of the other affections 
 of this group; but it is undeniably true that such an eruption is commonly 
 found in the victims of the disease if looked for carefully. 
 
 In the whole group (vaccinia excepted) certain lesions of the mouth, tonsils, 
 pharynx, larynx, and bronchi, varying from discrete or diffuse areas of conges¬ 
 tion to definite inflammatory processes, are commonly present. When diffuse, 
 these lesions are alike; only when discrete are they apt to present characters 
 
 275 
 
276 
 
 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 pathognomonic of any particular member of the group. While victims of cer¬ 
 tain of them are not particularly prone to develop inflammatory lesions of the 
 middle ear, accessory sinuses, tonsils, pharynx, bronchi, and lungs—often more 
 serious than the primary affections—such lesions not infrequently occur in per¬ 
 sons affected by the others. 
 
 In their mode of spread, chiefly if not invariably by personal contact (except 
 vaccinia), these diseases are strictly comparable. And again, excepting vac¬ 
 cinia,, their reaction to warm weather is in general the same. With few excep¬ 
 tions they all flourish only in the colder seasons, tending almost invariably 
 when endemic to die down during warm weather, to spring up in the autumn 
 and gather force, to reach their zenith in the winter or spring, and gradually 
 to subside with the development of warm weather. As a rule, also, when they 
 occur as epidemics, this general rule is adhered to. 
 
 All of them, except chicken-pox and vaccinia, have, as will appear later, 
 repeatedly entered Baltimore as epidemics, more or less widespread and fatal, 
 and have after a period of from one to several years, completely died out with¬ 
 out attacking, in recognizable form, all persons of susceptible age and not 
 previously affected. After repeated experiences of this character, small-pox, 
 measles, scarlet fever, and influenza have become endemically established. 
 In their known immunity reactions these diseases bear close resemblances. 
 As a rule, in each disease, with the probable exception of influenza, one attack 
 confers either at most complete and permanent immunity, or, at least, an im¬ 
 munity for a prolonged period with assurance of lightness of succeeding attacks. 
 It is characteristic of them all, though in varying degree, that during an attack 
 the resistance of the body as a whole, and of the respiratory tract in particular, 
 with the exception of vaccinia, is lowered to infection with pyogenic micro¬ 
 organisms, especially pneumococcus, streptococus, and staphylococcus. Two of 
 them, small-pox and vaccinia, are interchangeably protective, and the latter 
 in practice is available as a substitute for the former. These diseases, when 
 once established in large communities, have defied such attempts at interference 
 with their spread as household quarantine and disinfection. Household and 
 general sanitation, nuisance control (with the single exception of prevention 
 of the spread of scarlet fever by means of milk), and riches and poverty, are 
 all alike without discernible influence upon their course. Small-pox, restricted 
 doubtless to some degree by vaccination attacks incompletely organized, worked 
 its way effectively for many years. 
 
 All of these diseases share in common a proneness to attack the age group 
 1 to 20 or 30 years. 
 
 The illusive virus of each 1 has resisted discovery under repeated attacks 
 upon its identity with the use of all the resources of the microscopic and 
 cultural methods of modern microbiology. Ho one has been able to demonstrate, 
 in relation with the characteristic lesions of any of these affections, parasites 
 satisfactorily explaining them. In those members of this group which have 
 proved capable of transmission to laboratory animals, the viruses have been 
 shown to pass fine filters. 
 
 The specific virus of each member of the group appears to be able to resist dry¬ 
 ing. Ho convincing evidence exists that the virus of any of them requires an in¬ 
 termediate host either for development, preservation, or spread. The characters, 
 
 1 See footnote, p. 44. 
 
FEBRILE DISEASES 
 
 277 
 
 seats, and distributions of the essential lesions of all these diseases, as they 
 occur under natural conditions, indicate that their viruses are spread through¬ 
 out the body by means of the blood-vessels and have their primary and, in some 
 of them, their principal effect upon the blood-capillaries. Thus they all present 
 the typical indications of general rather than local affections. As if to em¬ 
 phasize these characteristics held in common by each of these diseases, with 
 the possible exception of vaccinia, in examples of unusual severity, hemorrhages 
 into the skin, mucous membranes, and even into certain organs are usual. 
 
 Points of difference, on the other hand, are not lacking. Vaccinia, under 
 natural conditions, in the present age at least, is not a peculiar disease of man. 
 Occurring, with few exceptions, only when transferred by inoculation, it is not 
 capable of propagating itself in this species indefinitely by contact or whatso¬ 
 ever other means usual for diseases of this group. Again, the incubation periods 
 of members of the group vary not only among the two divisions least alike, 
 but among those most alike in their superficial lesions. 
 
 In their finer details, the characteristic lesions of the diseases most alike 
 show differences which may be regarded as specific. It is unnecessary to indi¬ 
 cate other points of difference which will be evident enough to the initiated. 
 Enough has been brought forward to indicate that in the present discussion 
 it is not sought to prove identity, but to establish similarity among the members 
 of this in many ways peculiar group of diseases. 
 
 SMALL-POX. 
 
 There are no definite records of the prevalence and fatality of small-pox 
 in Baltimore before 1811, though, judging from the accounts of its prevalence 
 in Maryland in 1743, 1755, 1756, 1760, 1762, 1765, 1767, and 1771, and from 
 the activity of Dr. Henry Stevenson as an inoculator, it must have frequently 
 entered and spread in the town. In connection with the history of vaccination, 
 it is recorded that small-pox was prevalent in Baltimore in 1800, 1801, and 
 1810. The considerable epidemic of 1811-1812, with death-rates of 153 and 
 183 respectively, was the first one of consequence in the nineteenth century. 
 Except for a few cases in 1810, when the disease was said to have been “ soon 
 extinguished by vaccination,” small-pox had been absent several years. This 
 epidemic subsided as suddenly as it arose, and the disease did not reappear, 
 at least in fatal form, until 1816, when there were 2 deaths. Except for 1 
 death in 1818 and 1819, fatal small-pox was not again recorded until 1821. 
 It is worthy of note that, after this severe epidemic, the disease practically 
 died out for 10 years (table 34, graph 11). The few deaths recorded between 
 1813 and 1821 were apparently associated with very limited outbreaks, or with 
 isolated imported cases. It is certain that the city was free from recognized 
 small-pox in 1820. 
 
 The epidemic of 1821-1822, with death-rates of 35 in the former and 194 
 in the latter year, which was as sudden and unheralded as the one of 10 years 
 before, was traced to the importation of cases of small-pox on the ship Pallas. 
 The disease died down in 1823, but there were a few deaths each year until 
 1830, except in 1829, with rate varying from 2 to 9. Again the former experi¬ 
 ence was repeated, though not exactly, for in some years, at least, after the 
 subsidence of the epidemic, the disease was perhaps endemic. 
 
278 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 Table 34.— Number of deaths and rate of death, per 100,000 living inhabitants, from small¬ 
 pox, vaccinia, varicella, scarlet fever, measles, influenza, and total acute exanthematous 
 diseases excluding vaccinia, and percentage of the total deaths, from 1812 to 1920, inclusive. 
 
 Acute exanthematous diseases. 
 
 Year. 
 
 Small-pox. 
 
 Vaccinia. 
 
 Vari¬ 
 
 cella. 
 
 Scarlet 
 
 fever. 
 
 Measles. 
 
 In¬ 
 
 fluenza. 
 
 Total 
 
 (excluding 
 
 vaccinia). 
 
 Per cent, 
 of total 
 deaths 
 (excluding 
 vaccinia). 
 
 D 
 
 R 
 
 Vacci¬ 
 
 nations- 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 1811 
 
 
 60 
 
 153 
 
 
 
 
 
 
 
 
 
 
 
 60 
 
 153 
 
 • • 
 
 1812 
 
 • • • • 
 
 75 
 
 183 
 
 
 
 
 
 
 
 
 
 
 
 75 
 
 183 
 
 6 
 
 1813 
 
 
 
 
 
 
 
 
 
 
 33 
 
 77 
 
 
 
 33 
 
 77 
 
 3 
 
 1814 
 
 
 
 
 
 
 
 
 1 
 
 2 
 
 
 
 
 
 1 
 
 2 
 
 
 1815 
 
 
 
 
 
 
 
 
 
 
 8 
 
 17 
 
 25 
 
 53 
 
 33 
 
 71 
 
 2 
 
 1816 
 
 
 2 
 
 4 
 
 
 
 
 
 
 
 7 
 
 14 
 
 
 
 9 
 
 18 
 
 1 
 
 1817 
 
 
 
 
 . 
 
 
 
 
 
 
 
 
 
 
 
 • • 
 
 1818 
 
 
 1 
 
 2 
 
 
 
 
 
 
 
 
 
 2 
 
 4 
 
 3 
 
 6 
 
 
 1819 
 
 
 1 
 
 2 
 
 
 
 
 
 
 
 116 
 
 209 
 
 
 
 117 
 
 211 
 
 5 
 
 1820 
 
 
 
 
 
 
 
 
 4 
 
 7 
 
 
 
 
 
 4 
 
 7 
 
 
 1821 
 
 
 21 
 
 35 
 
 
 
 1 
 
 2 
 
 3 
 
 5 
 
 2 
 
 3 
 
 
 
 27 
 
 45 
 
 1 
 
 1822 
 
 
 122 
 
 194 
 
 
 
 
 
 
 
 4 
 
 6 
 
 
 
 126 
 
 201 
 
 6 
 
 1823 
 
 
 2 
 
 3 
 
 
 
 
 
 1 
 
 2 
 
 175 
 
 268 
 
 
 
 178 
 
 272 
 
 9 
 
 1824 
 
 
 2 
 
 3 
 
 
 
 
 
 
 
 14 
 
 21 
 
 
 
 16 
 
 24 
 
 1 
 
 1825 
 
 
 3 
 
 4 
 
 
 
 
 
 3 
 
 4 
 
 9 
 
 13 
 
 
 
 15 
 
 21 
 
 1 
 
 1826 
 
 
 5 
 
 7 
 
 
 
 
 
 
 
 3 
 
 4 
 
 
 
 8 
 
 11 
 
 
 1827 
 
 • • • • 
 
 7 
 
 9 
 
 4019 
 
 5251 
 
 
 
 
 
 1 
 
 1 
 
 
 
 8 
 
 10 
 
 i 
 
 1828 
 
 • • • • 
 
 2 
 
 3 
 
 
 
 
 
 
 
 
 
 
 
 2 
 
 3 
 
 # # 
 
 1829 
 
 • • • • 
 
 • • • • 
 
 • • • 
 
 2762 
 
 3474 
 
 • • • 
 
 • • • 
 
 1 
 
 1 
 
 46 
 
 56 
 
 
 
 47 
 
 57 
 
 3 
 
 1830 
 
 
 2 
 
 2 
 
 
 
 
 
 147 
 
 172 
 
 7 
 
 8 
 
 
 
 156 
 
 182 
 
 8 
 
 1831 
 
 
 25 
 
 28 
 
 3398 
 
 3824 
 
 
 
 161 
 
 181 
 
 23 
 
 26 
 
 11 
 
 12 
 
 220 
 
 248 
 
 10 
 
 1832 
 
 
 79 
 
 86 
 
 673 
 
 730 
 
 1 
 
 1 
 
 16 
 
 17 
 
 2 
 
 2 
 
 114 
 
 124 
 
 212 
 
 230 
 
 6 
 
 1833 
 
 
 32 
 
 34 
 
 
 
 
 
 141 
 
 148 
 
 12 
 
 13 
 
 
 
 185 
 
 194 
 
 8 
 
 1834 
 
 
 71 
 
 72 
 
 1068 
 
 1080 
 
 1 
 
 1 
 
 143 
 
 145 
 
 77 
 
 78 
 
 9 
 
 9 
 
 300 
 
 303 
 
 12 
 
 1835 
 
 
 3 
 
 3 
 
 
 
 
 
 13 
 
 13 
 
 5 
 
 5 
 
 13 
 
 13 
 
 34 
 
 33 
 
 2 
 
 1836 
 
 • • • • 
 
 1 
 
 1 
 
 130 
 
 123 
 
 ... 
 
 • • • 
 
 30 
 
 28 
 
 1 
 
 1 
 
 • • • 
 
 • • • 
 
 32 
 
 30 
 
 « 1 
 
 1837 
 
 • • • • 
 
 53 
 
 48 
 
 2753 
 
 2512 
 
 4 
 
 4 
 
 134 
 
 122 
 
 141 
 
 129 
 
 • • • 
 
 • • • 
 
 332 
 
 303 
 
 13 
 
 1838 
 
 • • • • 
 
 72 
 
 64 
 
 1000 
 
 882 
 
 2 
 
 2 
 
 141 
 
 124 
 
 4 
 
 4 
 
 • • • 
 
 • • • 
 
 219 
 
 193 
 
 9 
 
 1839 
 
 • • • • 
 
 2 
 
 2 
 
 2213 
 
 1889 
 
 1 
 
 1 
 
 112 
 
 96 
 
 57 
 
 49 
 
 • • • 
 
 • • • 
 
 172 
 
 147 
 
 8 
 
 1840 
 
 
 11 
 
 9 
 
 
 
 3 
 
 2 
 
 71 
 
 59 
 
 32 
 
 26 
 
 
 
 117 
 
 97 
 
 6 
 
 1841 
 
 
 1 
 
 1 
 
 
 
 1 
 
 1 
 
 74 
 
 59 
 
 6 
 
 5 
 
 
 
 82 
 
 66 
 
 4 
 
 1842 
 
 
 1 
 
 1 
 
 2655 
 
 2058 
 
 
 • • • 
 
 27 
 
 21 
 
 103 
 
 80 
 
 • • • 
 
 • • • 
 
 131 
 
 102 
 
 5 
 
 1843 
 
 • • • • 
 
 • • • • 
 
 • • • 
 
 2254 
 
 1694 
 
 • • • 
 
 • • • 
 
 56 
 
 42 
 
 4 
 
 3 
 
 9 
 
 7 
 
 69 
 
 52 
 
 3 
 
 1844 
 
 
 
 
 
 
 
 
 370 
 
 270 
 
 1 
 
 1 
 
 
 
 371 
 
 270 
 
 14 
 
 1845 
 
 .... 
 
 110 
 
 78 
 
 3367 
 
 2379 
 
 • • • 
 
 • • • 
 
 288 
 
 204 
 
 20 
 
 14 
 
 1 
 
 1 
 
 419 
 
 296 
 
 14 
 
 1846 
 
 • • • • 
 
 115 
 
 79 
 
 3707 
 
 2542 
 
 1 
 
 1 
 
 132 
 
 91 
 
 114 
 
 78 
 
 • • • 
 
 • • • 
 
 362 
 
 248 
 
 12 
 
 1847 
 
 • • • • 
 
 2 
 
 1 
 
 1805 
 
 1201 
 
 1 
 
 1 
 
 166 
 
 110 
 
 7 
 
 5 
 
 • • • 
 
 • • • 
 
 176 
 
 117 
 
 5 
 
 1848 
 
 • • • • 
 
 5 
 
 3 
 
 1763 
 
 1139 
 
 • • • 
 
 • • • 
 
 407 
 
 263 
 
 74 
 
 48 
 
 • • • 
 
 • • • 
 
 486 
 
 314 
 
 13 
 
 1849 
 
 • • • • 
 
 20 
 
 13 
 
 2159 
 
 1355 
 
 1 
 
 1 
 
 154 
 
 97 
 
 31 
 
 19 
 
 4 
 
 3 
 
 210 
 
 132 
 
 5 
 
 1850 
 
 • • • • 
 
 153 
 
 93 
 
 1987 
 
 1212 
 
 3 
 
 2 
 
 225 
 
 137 
 
 7 
 
 4 
 
 1 
 
 1 
 
 389 
 
 237 
 
 9 
 
 1851 
 
 • • • • 
 
 104 
 
 62 
 
 3738 
 
 2217 
 
 3 
 
 2 
 
 234 
 
 139 
 
 21 
 
 12 
 
 • • • 
 
 
 362 
 
 215 
 
 9 
 
 1852 
 
 • • • • 
 
 66 
 
 38 
 
 1948 
 
 1123 
 
 ■ • • 
 
 • • • 
 
 232 
 
 134 
 
 314 
 
 181 
 
 • • • 
 
 
 612 
 
 353 
 
 12 
 
 1853 
 
 • • • • 
 
 9 
 
 5 
 
 1604 
 
 900 
 
 • • • 
 
 • • • 
 
 362 
 
 203 
 
 16 
 
 9 
 
 • • • 
 
 
 387 
 
 217 
 
 8 
 
 1854 
 
 • • • • 
 
 26 
 
 14 
 
 2513 
 
 1371 
 
 1 
 
 1 
 
 234 
 
 128 
 
 99 
 
 54 
 
 • • • 
 
 
 360 
 
 196 
 
 7 
 
 1855 
 
 • • • • 
 
 50 
 
 27 
 
 3910 
 
 2077 
 
 6 
 
 3 
 
 131 
 
 70 
 
 14 
 
 7 
 
 • • • 
 
 
 201 
 
 107 
 
 4 
 
 1856 
 
 • • • • 
 
 8 
 
 4 
 
 2236 
 
 1156 
 
 3 
 
 2 
 
 222 
 
 115 
 
 8 
 
 4 
 
 • • • 
 
 
 241 
 
 125 
 
 5 
 
 1857 
 
 • • • • 
 
 91 
 
 46 
 
 4121 
 
 2076 
 
 2 
 
 1 
 
 353 
 
 178 
 
 205 
 
 103 
 
 # 
 
 
 651 
 
 328 
 
 13 
 
 1858 
 
 
 310 
 
 152 
 
 8576 
 
 4209 
 
 • • • 
 
 • • • 
 
 535 
 
 263 
 
 39 
 
 19 
 
 • • • 
 
 
 884 
 
 434 
 
 16 
 
 1859 
 
 • • • • 
 
 1 
 
 • • • 
 
 1770 
 
 847 
 
 • • • 
 
 • • • 
 
 301 
 
 144 
 
 57 
 
 27 
 
 • • • 
 
 
 359 
 
 172 
 
 8 
 
 1860 
 
 • • • • 
 
 • • • • 
 
 • • • 
 
 2277 
 
 1062 
 
 • • • 
 
 • • • 
 
 116 
 
 54 
 
 109 
 
 51 
 
 • • • 
 
 
 225 
 
 105 
 
 5 
 
 1861 
 
 • • • • 
 
 1 
 
 * • • 
 
 2992 
 
 1360 
 
 3 
 
 1 
 
 252 
 
 115 
 
 11 
 
 5 
 
 • • • 
 
 
 267 
 
 121 
 
 6 
 
 1862 
 
 • • • • 
 
 34 
 
 15 
 
 1663 
 
 737 
 
 • • • 
 
 • • • 
 
 575 
 
 255 
 
 154 
 
 68 
 
 
 
 763 
 
 338 
 
 15 
 
 1863 
 
 • • • • 
 
 252 
 
 109 
 
 2862 
 
 1238 
 
 2 
 
 1 
 
 339 
 
 147 
 
 17 
 
 7 
 
 • • • 
 
 
 610 
 
 264 
 
 11 
 
 1864 
 
 • • • • 
 
 436 
 
 184 
 
 6044 
 
 2552 
 
 4 
 
 2 
 
 136 
 
 57 
 
 143 
 
 60 
 
 • • • 
 
 
 719 
 
 304 
 
 13 
 
 1865 
 
 .... 
 
 18 
 
 7 
 
 2315 
 
 954 
 
 • • • 
 
 ... 
 
 86 
 
 35 
 
 11 
 
 5 
 
 ... 
 
 
 115 
 
 47 
 
 2 
 
FEBRILE DISEASES 
 
 279 
 
 Table 34. —Number of deaths and rate of death, per 100,000 living inhabitants, from small¬ 
 pox, vaccinia, varicella, scarlet fever, measles, influenza, etc. —Continued. 
 
 Acute exanthematous diseases. 
 
 Small-pox. 
 
 Vaccinia. 
 
 Vari¬ 
 
 cella. 
 
 Scarlet 
 
 fever. 
 
 Measles. 
 
 In¬ 
 
 fluenza. 
 
 Total 
 
 (excluding 
 
 vaccinia). 
 
 Per cent, 
 of total 
 deaths 
 
 I) 
 
 R 
 
 Vacci¬ 
 
 nations- 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 (excluding 
 
 vaccinia). 
 
 1866 
 
 • • • • 
 
 13 
 
 5 
 
 2076 
 
 835 
 
 1 
 
 • • • 
 
 121 
 
 49 
 
 105 
 
 42 
 
 
 
 240 
 
 97 
 
 4 
 
 1867 
 
 • • • • 
 
 
 
 891 
 
 350 
 
 1 
 
 • • • 
 
 137 
 
 54 
 
 8 
 
 3 
 
 
 
 146 
 
 57 
 
 3 
 
 1868 
 
 • • • • 
 
 
 
 2216 
 
 851 
 
 • • • 
 
 • • • 
 
 127 
 
 49 
 
 196 
 
 75 
 
 
 
 323 
 
 124 
 
 5 
 
 1869 
 
 • • • • 
 
 
 
 1822 
 
 684 
 
 • • • 
 
 -• • • 
 
 171 
 
 64 
 
 227 
 
 85 
 
 
 
 398 
 
 149 
 
 6 
 
 1870 
 
 • • • • 
 
 
 
 1329 
 
 487 
 
 3 
 
 1 
 
 256 
 
 94 
 
 35 
 
 13 
 
 
 
 294 
 
 108 
 
 4 
 
 1871 
 
 • • • • 
 
 
 
 5364 
 
 1923 
 
 4 
 
 1 
 
 625 
 
 224 
 
 111 
 
 40 
 
 
 
 740 
 
 265 
 
 10 
 
 1872 
 
 • • • • 
 
 1043 
 
 366 
 
 50650 
 
 17756 
 
 4 
 
 1 
 
 141 
 
 49 
 
 161 
 
 56 
 
 
 
 1349 
 
 473 
 
 15 
 
 1873 
 
 • • • • 
 
 469 
 
 161 
 
 87739 
 
 30084 
 
 • • • 
 
 • • • 
 
 115 
 
 39 
 
 46 
 
 16 
 
 
 
 630 
 
 216 
 
 8 
 
 1874 
 
 • • • • 
 
 0000 
 
 
 1136 
 
 381 
 
 3 
 
 1 
 
 234 
 
 78 
 
 93 
 
 31 
 
 
 
 330 
 
 111 
 
 4 
 
 1875 
 
 • • • • 
 
 1 
 
 
 1741 
 
 571 
 
 • • • 
 
 
 519 
 
 170 
 
 15 
 
 5 
 
 
 
 535 
 
 176 
 
 7 
 
 1876 
 
 • • • • 
 
 • • • • 
 
 
 1634 
 
 525 
 
 • • • 
 
 
 562 
 
 181 
 
 16 
 
 5 
 
 
 
 578 
 
 186 
 
 8 
 
 1877 
 
 • 0 • • 
 
 • • • • 
 
 
 3397 
 
 1068 
 
 • • • 
 
 
 447 
 
 141 
 
 151 
 
 47 
 
 
 
 598 
 
 188 
 
 8 
 
 1878 
 
 • • • • 
 
 1 
 
 
 1457 
 
 449 
 
 • • • 
 
 
 141 
 
 43 
 
 11 
 
 3 
 
 
 
 153 
 
 47 
 
 2 
 
 1879 
 
 • • • • 
 
 1 
 
 
 2186 
 
 659 
 
 1 
 
 
 367 
 
 111 
 
 43 
 
 13 
 
 1 
 
 
 413 
 
 125 
 
 5 
 
 1880 
 
 • • • • 
 
 1 
 
 
 8467 
 
 2501 
 
 000 
 
 
 400 
 
 118 
 
 12 
 
 4 
 
 
 
 413 
 
 122 
 
 5 
 
 1881 
 
 
 11 
 
 3 
 
 20100 
 
 5816 
 
 2 
 
 1 
 
 215 
 
 62 
 
 75 
 
 22 
 
 1 
 
 
 304 
 
 88 
 
 3 
 
 1882 
 
 
 551 
 
 156 
 
 94693 
 
 26850 
 
 • • • 
 
 
 179 
 
 51 
 
 71 
 
 20 
 
 
 
 801 
 
 227 
 
 9 
 
 1883 
 
 • • • • 
 
 633 
 
 176 
 
 217050 
 
 60319 
 
 1 
 
 
 334 
 
 93 
 
 130 
 
 36 
 
 
 
 1098 
 
 305 
 
 12 
 
 1884 
 
 • • • • 
 
 1 
 
 
 1567 
 
 427 
 
 3 
 
 1 
 
 104 
 
 28 
 
 228 
 
 62 
 
 
 
 336 
 
 92 
 
 4 
 
 1885 
 
 • • • • 
 
 • • • • 
 
 
 2012 
 
 537 
 
 000 
 
 
 68 
 
 18 
 
 16 
 
 4 
 
 
 
 84 
 
 22 
 
 1 
 
 1886 
 
 • • • • 
 
 1 
 
 
 3042 
 
 797 
 
 000 
 
 
 32 
 
 8 
 
 201 
 
 53 
 
 
 
 234 
 
 61 
 
 3 
 
 1887 
 
 • • • • 
 
 
 
 4066 
 
 1045 
 
 1 
 
 
 36 
 
 9 
 
 85 
 
 22 
 
 
 
 122 
 
 31 
 
 1 
 
 1888 
 
 • • • • 
 
 
 
 7458 
 
 1778 
 
 • • • 
 
 
 44 
 
 10 
 
 176 
 
 42 
 
 
 
 220 
 
 52 
 
 2 
 
 1889 
 
 • • • • 
 
 
 
 7411 
 
 17 35 
 
 • • • 
 
 
 71 
 
 17 
 
 11 
 
 3 
 
 
 
 82 
 
 19 
 
 1 
 
 1890 
 
 • • • • 
 
 
 
 11281 
 
 2596 
 
 • • • 
 
 
 42 
 
 10 
 
 248 
 
 57 
 
 17 
 
 4 
 
 307 
 
 71 
 
 3 
 
 1891 
 
 • • • • 
 
 
 
 10703 
 
 2421 
 
 3 
 
 1 
 
 128 
 
 29 
 
 16 
 
 4 
 
 244 
 
 55 
 
 391 
 
 88 
 
 4 
 
 1892 
 
 • • • • 
 
 
 
 33249 
 
 7398 
 
 1 
 
 
 258 
 
 57 
 
 120 
 
 27 
 
 190 
 
 42 
 
 569 
 
 127 
 
 5 
 
 1893 
 
 • • • • 
 
 
 
 20875 
 
 4570 
 
 1 
 
 
 36 
 
 8 
 
 39 
 
 9 
 
 62 
 
 14 
 
 138 
 
 30 
 
 • • 
 
 1894 
 
 • • • • 
 
 
 
 42042 
 
 9059 
 
 1 
 
 
 85 
 
 18 
 
 3 
 
 1 
 
 132 
 
 28 
 
 221 
 
 48 
 
 • • 
 
 1895 
 
 0,00 
 
 
 
 12990 
 
 2755 
 
 • • • 
 
 
 59 
 
 13 
 
 68 
 
 14 
 
 185 
 
 39 
 
 312 
 
 66 
 
 3 
 
 1896 
 
 • • • • 
 
 
 
 13759 
 
 2875 
 
 2 
 
 
 31 
 
 6 
 
 27 
 
 6 
 
 60 
 
 13 
 
 120 
 
 25 
 
 1 
 
 1897 
 
 • • • • 
 
 
 
 12905 
 
 2656 
 
 1 
 
 
 53 
 
 11 
 
 16 
 
 3 
 
 88 
 
 18 
 
 158 
 
 33 
 
 2 
 
 1898 
 
 • • • • 
 
 
 
 11817 
 
 2397 
 
 • • • 
 
 
 46 
 
 9 
 
 48 
 
 10 
 
 70 
 
 14 
 
 164 
 
 33 
 
 2 
 
 1899 
 
 • • • • 
 
 1 
 
 
 36491 
 
 7296 
 
 
 
 24 
 
 5 
 
 5 
 
 1 
 
 231 
 
 46 
 
 261 
 
 52 
 
 3 
 
 1900 
 
 • • • • 
 
 
 
 9023 
 
 1780 
 
 ,00 
 
 
 20 
 
 4 
 
 24 
 
 5 
 
 77 
 
 15 
 
 121 
 
 24 
 
 1 
 
 1901 
 
 • • • • 
 
 
 
 15400 
 
 2997 
 
 1 
 
 
 11 
 
 2 
 
 3 
 
 1 
 
 128 
 
 25 
 
 143 
 
 28 
 
 1 
 
 1902 
 
 • • • • 
 
 7 
 
 1 
 
 46412 
 
 8913 
 
 • • • 
 
 
 37 
 
 7 
 
 41 
 
 8 
 
 28 
 
 5 
 
 113 
 
 22 
 
 1 
 
 1903 
 
 • • • • 
 
 2 
 
 
 11566 
 
 2193 
 
 • • • 
 
 
 84 
 
 16 
 
 77 
 
 15 
 
 92 
 
 17 
 
 255 
 
 48 
 
 3 
 
 1904 
 
 • • • • 
 
 4 
 
 1 
 
 23440 
 
 4389 
 
 1 
 
 
 143 
 
 27 
 
 6 
 
 1 
 
 122 
 
 23 
 
 276 
 
 52 
 
 3 
 
 1905 
 
 • • • • 
 
 
 
 5979 
 
 1106 
 
 1 
 
 
 33 
 
 6 
 
 67 
 
 12 
 
 91 
 
 17 
 
 192 
 
 36 
 
 2 
 
 1906 
 
 0 0 0 0 
 
 
 
 9319 
 
 1703 
 
 4 
 
 1 
 
 47 
 
 9 
 
 14 
 
 3 
 
 54 
 
 10 
 
 119 
 
 22 
 
 1 
 
 1907 
 
 0 0 0 0 
 
 
 
 3769 
 
 681 
 
 • • • 
 
 
 15 
 
 3 
 
 74 
 
 13 
 
 105 
 
 19 
 
 194 
 
 35 
 
 2 
 
 1908 
 
 0 0 0 0 
 
 
 
 5926 
 
 1058 
 
 ■ • • 
 
 
 70 
 
 13 
 
 17 
 
 3 
 
 173 
 
 31 
 
 260 
 
 46 
 
 2 
 
 1909 
 
 0 0 0 0 
 
 
 
 1277 
 
 226 
 
 0 0 
 
 
 25 
 
 4 
 
 54 
 
 10 
 
 79 
 
 14 
 
 158 
 
 28 
 
 2 
 
 1910 
 
 0 0 0 0 
 
 
 
 8161 
 
 1426 
 
 1 
 
 
 49 
 
 9 
 
 19 
 
 3 
 
 72 
 
 13 
 
 141 
 
 25 
 
 1 
 
 1911 
 
 0 0 0 0 
 
 
 
 7561 
 
 1307 
 
 m 0 0 
 
 
 44 
 
 8 
 
 77 
 
 13 
 
 86 
 
 15 
 
 207 
 
 36 
 
 2 
 
 1912 
 
 0 0 0 0 
 
 
 
 4663 
 
 798 
 
 1 
 
 
 23 
 
 4 
 
 5 
 
 1 
 
 71 
 
 12 
 
 100 
 
 17 
 
 1 
 
 1913 
 
 0 0 0 0 
 
 
 
 27424 
 
 4648 
 
 000 
 
 
 40 
 
 7 
 
 118 
 
 20 
 
 48 
 
 8 
 
 206 
 
 35 
 
 2 
 
 1914 
 
 0 0 0 0 
 
 3 
 
 1 
 
 15693 
 
 2634 
 
 6 
 
 1 
 
 39 
 
 7 
 
 6 
 
 1 
 
 72 
 
 12 
 
 126 
 
 21 
 
 1 
 
 1915 
 
 • • » * 
 
 
 
 7223 
 
 1201 
 
 0 0 , 
 
 
 33 
 
 5 
 
 17 
 
 3 
 
 97 
 
 16 
 
 147 
 
 24 
 
 1 
 
 1916 
 
 0 0 0 0 
 
 
 
 6515 
 
 1073 
 
 2 
 
 
 30 
 
 5 
 
 34 
 
 6 
 
 129 
 
 21 
 
 195 
 
 32 
 
 2 
 
 1917 
 
 0 0 0 0 
 
 
 
 8894 
 
 1452 
 
 000 
 
 
 11 
 
 2 
 
 51 
 
 8 
 
 108 
 
 18 
 
 170 
 
 28 
 
 2 
 
 1918 
 
 0 0 0 0 
 
 
 
 10230 
 
 1656 
 
 4 
 
 1 
 
 8 
 
 1 
 
 75 
 
 12 
 
 1741 
 
 282 
 
 1828 
 
 296 
 
 11 
 
 1919 
 
 
 
 
 
 
 4 
 
 1 
 
 30 
 
 4 
 
 7 
 
 1 
 
 406 
 
 56 
 
 447 
 
 62 
 
 4 
 
 1920 
 
 
 
 
 
 
 3 
 
 
 13 
 
 2 
 
 49 
 
 7 
 
 324 
 
 44 
 
 389 
 
 53 
 
 3 
 
280 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 It will be well here to consider very briefly the character and extent of the 
 protective measures against small-pox up to 1830. Inoculation against small¬ 
 pox is said to have been practiced in Maryland since shortly after its introduc¬ 
 tion into England in 1717. Besides other well-known inoculators in Maryland, 
 there was the widely celebrated Richard Brooke, of Prince George County, who 
 devised the “ American method ” described in a tract published by Benjamin 
 Franklin in 1730, and afterwards widely adopted. Dr. Henry Stevenson, one 
 of the most successful inoculators, practiced the art in Baltimore as early as 
 1755, and maintained for many years an inoculation hospital in the suburbs 
 of Baltimore Town. His charges were 2 pistoles (perhaps 32 shillings) for 
 inoculation and 20 shillings a week for board and lodging. It is probable, 
 
 LOGO Ff. 
 
 - SMALLPOX. 
 
 - varicella 
 
 - INFLUENZA 
 
 YEAR 
 
 Graph 11 (from table 34). Annual crude mortality rates from small-pox, 
 varicella and influenza, from 1812 to 1920, inclusive. 
 
 therefore, that on account of the cost and the scant hospital accommodations 
 available, the protection of inoculation was within the reach of only the very 
 well-to-do. The procedure was, however, held in high esteem, and was con¬ 
 tinued to some extent until abolished by law in 1850. 
 
 Vaccination against small-pox was first practiced in Baltimore in the summer 
 of 1800, by Dr. John Crawford, with virus received from Ring, of London. 
 The second supply of vaccine virus, obtained some months later from London, 
 through Mr. William Taylor, came into the hands of Dr. James Smith, attend¬ 
 ing physician to the almshouse. On May 1, 1801, Dr. Smith vaccinated a girl 
 of 7 years, and later a considerable number of other patients at the almshouse. 
 It is narrated that, though all of Smith’s cases were exposed to small-pox, then 
 prevalent, none contracted the disease. Though the virus was freely offered, 
 no one could then be prevailed upon to use it generally. In 1802, Dr. Smith 
 
FEBRILE DISEASES 
 
 281 
 
 established a vaccine institute, which, in one form or another, he maintained 
 for many years. Their first doubts removed by the success of Smith’s experi¬ 
 ments, the local physicians became ardent vaccinationists. The faculty endorsed 
 the procedure in 1802 and again in 1805. During the small-pox epidemic of 
 1812 the members offered to vaccinate gratuitously all who applied and to pay 
 25 cents to each child presenting proof of genuine vaccination. 
 
 A lottery was granted in 1809 to extend the work of the Vaccine Institute, 
 and in 1812 a vaccine society was organized by leading citizens. In that year 
 the society was responsible for 994 vaccinations, 694 of which were gratuitous. 
 About this time, too, the National Vaccine Institute was established in Balti¬ 
 more under Dr. Smith’s direction. 
 
 During the epidemic year 1821, at the suggestion of the faculty, a vaccine 
 physician was appointed in each ward to vaccinate the poor, and this became 
 a permanent feature of the public-health organization in 1824. At this time, 
 too, the health department became responsible for having on hand a pure and 
 potent vaccine virus. Up to 1827, administrative efforts to control small-pox 
 by vaccination were limited to furnishing virus freely, providing free vaccina¬ 
 tion to the poor, and employing moral suasion to promote its general adoption. 
 
 In April of this year, when small-pox, introduced in virulent form by 
 shipping, was spreading rapidly, and many, particularly among the free negroes, 
 refused vaccination, the health department was granted power to vaccinate all 
 persons in the neighborhood of cases of small-pox, and, in a short time, 517 
 persons were vaccinated under this provision. This law remained the main 
 dependence of the health department in fighting actual outbreaks of small-pox 
 until greater powers were conferred by the ordinance and the State law of 1864. 
 There is no record of the number of public vaccinations prior to 1827. For 
 this year, when the deaths from small-pox numbered only 9, the four vaccine 
 physicians were credited with performing 4,019 vaccinations, a rate of 5,251 
 (table 34). For 1829 the vaccination-rate was 3,474. No record was made of 
 the number of vaccinations for 1828 and 1830. There is little doubt that the 
 proportion of public vaccinations was much greater after than before the con¬ 
 ferring of greater powers upon the health department in 1827. It is probably 
 fair to assume that during the epidemics of 1811-1812 and 1821-1822, under 
 the influence of the propaganda conducted by the medical profession, the 
 vaccine society, and the health department, a very considerable proportion of 
 the better-to-do and more intelligent of the population were vaccinated at 
 least once, and that during the last epidemic a considerable number of the 
 poorer classes availed themselves of the services of the vaccine physicians. 
 It is likely that by 1830 a very considerable proportion, but certainly not more 
 than one-half, of the population had been vaccinated. 
 
 During this period the health department possessed the right to enforce 
 isolation of small-pox cases and contacts in houses and institutions, to clean 
 and disinfect the latter, and to destroy infected clothing, bedding, and the like. 
 But its personnel and machinery for exercising its power were wofully deficient. 
 Case reporting, except by tavern and boarding-house keepers and masters of 
 vessels in the harbor, was voluntary. In times of epidemic, the few police were 
 called upon to act as searchers and watchmen, and, though the vaccine physi¬ 
 cians were doubtless ever on the watch for small-pox cases and must have been 
 
282 PUBLIC HEALTH ADMINISTRATION", ETC., IN BALTIMORE 
 
 in position to hear of cases seen by physicians, many hidden cases among free 
 negroes and recent immigrants must have escaped them. 
 
 Practically speaking, there were no adequate hospital facilities. The small 
 hospital building at Hawkins’ Point was distant and difficult of access. The 
 accommodations at the lazaretto were scanty and not sufficient to care for 
 patients and suspects from the extensive shipping. 
 
 While small-pox was certainly included in the list of “ pestilential diseases ” 
 against which maritime quarantine applied, time and again cases filtered 
 through the wide meshes of its sieve. Quarantine by land was not attempted. 
 
 The conclusion is inevitable that the course of small-pox in Baltimore during 
 the period under consideration was not materially influenced by artificial inter¬ 
 ferences of the ordinary sort, and that during the period previous to 1827 the 
 natural history of the disease could not have been very seriously modified by 
 vaccination. 
 
 The year 1831 ushered in a new phase which lasted until 1866. During the 
 period of 36 years in only four years were deaths not recorded, and probably in 
 no year did the city lack cases. Very characteristic of this period was the 
 occurrence of numbers of outbreaks or minor epidemic waves with low mortality 
 rates as compared with the previous epidemics and extending over from 2 to 4 
 years. The intervals between the outbreaks varied from one to several years. 
 It appears that during most of this period small-pox was endemically estab¬ 
 lished, and that these repeated outbreaks were due in part to exacerbations of 
 the indigenous disease and in part to new importations. 
 
 The first of these minor outbreaks, extending over the 4 years 1831-1834 
 ran a somewhat irregular course, with rates of 28, 86, 34, and 72 for the several 
 years. The rates dropped abruptly to 3 in 1835 and to 1 in 1836. This out¬ 
 break was, to some degree at least, modified by administrative measures. 
 A small hospital for small-pox cases had been established within the city, and 
 vaccination, with virus renewed by “ passage ” through a cow, was pushed. 
 According to Dr. Jameson’s report, 6,000 persons were vaccinated in 1831, 
 though the official number credited to the vaccine physicians was under 4,000. 
 Unfortunately, the figures for vaccination were not given in the reports for 
 1833 and 1835. The vaccination-rates for 1832, 1834 and 1836 are very low. 
 Dr. Jameson attributed the continued prevalence of small-pox to the fact that 
 many persons who had been properly vaccinated in childhood neglected vaccina¬ 
 tion at puberty. His demand for general compulsory vaccination was not 
 granted. 
 
 The second wave, marked by rates of 48 in 1837 and 64 in 1838, subsided 
 in 1839, and in two of the following four years no deaths were recorded. The 
 vaccinations were recorded too irregularly to permit judgment in regard to 
 their effect upon the disease at this time. There were flare-ups of the disease 
 with moderately high death-rates in 1845-1846, 1849-1852, and 1854-1855. 
 The vaccination-rate was relatively high only in 1845, 1846, 1851, and 1855. 
 After 1846, a considerable number of small-pox cases were sent to the new 
 Marine Hospital, and as the deaths among these were not credited to the city, 
 the mortality rates calculated on the official figures after this date are lower 
 than actual experience. 
 
 The considerable epidemic of 1857-1858, with rates of 46 and 152, was 
 associated with a high vaccination-rate (4,209) in the latter year. With the 
 
FEBRILE DISEASES 
 
 283 
 
 subsidence of this outbreak the disease lay dormant until 1862, when there 
 began a serious epidemic which lasted over the Civil War. Death-rates of 109 
 and 184 were attained in 1863 and 1864. The vaccination-rates were relatively 
 low—2,552 in 1864 being the highest. 
 
 During much if not most of this period the administrative measures designed 
 to control the spread of the disease were very lax. As late as 1857 complaint 
 was made in the annual report that vaccination was very incomplete, that 
 unvaccinated persons in the incubative stage of small-pox moved at will from 
 infected to non-infected districts, and that convalescents were freed from 
 quarantine too early. As evidence of the insufficiency of the system of non- 
 compulsory vaccination in effect, it was pointed out that in December 1857, in 
 the midst of an epidemic, in 1,173 calls at houses the vaccinators performed 
 only 1,637 vaccinations. The weakness of the administration’s position is evi¬ 
 dent from the fact that this number comprised nearly half the public vaccina¬ 
 tions performed that year. 
 
 The conferring of greater powers to the health department by the city 
 government, and the establishment by the State legislature of compulsory 
 vaccination of children before the end of the first year and the State vaccine 
 agency, all in 1864, were reflections of the severe epidemic of 1862-1864. 
 Strangely little allusion was made to the epidemic of the Civil War period, 
 Fortunately, Charles Frick published, in 1855, data from which may be drawn 
 a clear picture of the distribution of deaths from small-pox by color, sex, and 
 age. In his analysis of the deaths from small-pox for the year 1850 in Balti¬ 
 more, Frick, who had access to the original records, found that, for the whites 
 the deaths were 8.1 and for the blacks 14.5 to 10,000 inhabitants, or nearly 
 double among the latter race. The disease was more fatal to males than to 
 females in the proportion of 60.6 per cent of the first to 39.4 per cent of the 
 latter. The proportion of the deaths, at different ages, is shown in table 35. 
 
 Table 35. 
 
 p. c. 
 
 Under 1 year. 18.0 
 
 Between 1 and 5 years. 30.8 
 
 Between 5 and 10 years. 7.5 
 
 Between 10 and 20 years. 7.7 
 
 Between 20 and 30 years. 17.0 
 
 Between 30 and 60 years. 17.3 
 
 Over 60 years. 1.7 
 
 The death-rates specific for age are given in table 36. 
 
 The high rates obtaining among infants and young children indicates that 
 the routine vaccination of children in the first or second year of life had not 
 yet become a general custom in the community. 
 
 After an absence of 4 years, small-pox made its appearance in Baltimore 
 in November 1871, following the importation of a case from Philadelphia, 
 where the disease was prevalent in severe form. There were no deaths registered 
 in 1871, but in January and February 1872 there were 1 and 14 deaths respec¬ 
 tively. Thus by March there was well under way an epidemic which lasted 
 until July 1873, and which proved to be the severest in the city’s history. The 
 course of the disease as marked by the monthly annual mortality rates is well 
 shown on table 37. The dip in the curve during August, September, October, 
 19 
 
284 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 and November 1872, may be ascribed partly to the well-known influence of 
 season and partly to the efforts of the health department, particularly in 
 pushing vaccination. However this may be, after a very rapid and steep ascent, 
 the highest peak in the curve was reached in July 1872, with a monthly annual 
 death-rate of 1,081. This was followed by the abrupt fall to a relatively low 
 level for 4 months, which in turn was succeeded by a sharp rise, beginning in 
 December and reaching its high point in January 1873, with a monthly annual 
 rate of 755. From this point there was a gradual fall with the culmination of 
 the epidemic in July. The annual death-rates for 1872 and 1873 were 366 
 and 161, respectively. This picture is, however, only relatively and not actually 
 correct, for it is drawn from rates calculated only on the deaths that occurred 
 within the city, no account being taken of the considerable number of deaths 
 among city cases sent to the Marine Hospital or pest-house without the city 
 
 Table 36. —Number of deaths and rate of death, per 
 100,000 living inhabitants, from small-pox and scar¬ 
 let fever, according to age, for 1850. Calculated 
 from figures given in Frick’s tables. 
 
 Age period. 
 
 Small-pox. 
 
 Scarlet fever. 
 
 D 
 
 R 
 
 D 
 
 R 
 
 i 
 
 Under 1 year. 
 
 28 
 
 457 
 
 24 
 
 392 
 
 1 to 4 years. 
 
 48 
 
 260 
 
 134 
 
 727 
 
 5 to 9 years. 
 
 12 
 
 60 
 
 45 
 
 224 
 
 Under 10 years. 
 
 88 
 
 197 
 
 203 
 
 455 
 
 10 to 19 years. 
 
 11 
 
 30 
 
 21 
 
 57. 
 
 20 to 29 years. 
 
 26 
 
 76 
 
 1 
 
 3 
 
 30 to 39 years. 
 
 11 
 
 45 
 
 • • • 
 
 • • • 
 
 40 to 49 years. 
 
 14 
 
 96 
 
 • • • 
 
 • • • 
 
 50 to 59 years. 
 
 3 
 
 37 
 
 • • • 
 
 • • • 
 
 60 years and over. 
 
 3 
 
 47 
 
 • • • 
 
 • • • 
 
 Total . 
 
 156 
 
 92 
 
 225 
 
 133 
 
 limits. These included many of the worst cases, some of which were moribund 
 on their arrival. As separate accounts were not reported of the cases and deaths 
 of citizens of Baltimore and of the sailors and passengers with small-pox 
 removed at quarantine from foreign ships and sent to the Marine Hospital, it is 
 not possible to determine the number of deaths among the former at that insti¬ 
 tution. During the period of the epidemic there were treated at the Marine 
 Hospital a total of 1,016 cases of small-pox with 533 deaths and 246 cases of 
 varioloid with 6 deaths, and the great majority at least of these occurred in 
 persons sent from the city. There were at the hospital, 682 cases of small-pox 
 with 316 deaths in 1872 and 334 cases with 217 deaths in 1873 and 124 
 cases of varioloid with 6 deaths in the former year and 122 cases and no deaths 
 in the latter. The proportional distribution of the deaths of small-pox in the 
 city (1,043 in 1872 and 469 in 1873) and at the hospital in these two years was 
 in the neighborhood of 3 to 1 in 1872 and 2 to 1 in 1873. When the number of 
 deaths occurring at the Marine Hospital—nearly all among patients sent from 
 the city—are added to the figures as given in the official list, the total number 
 
FEBRILE DISEASES 
 
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 ■ —I _ d _< _ l 1 _ l _ 1 _ l _, _ 1 _ I _ i _ I _■ _ I _ 1 _ I - 1 __d —A —I —i 
 
 Those years in which deaths did not occur have been omitted from this table. 
 
286 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 of deaths attributable to small-pox was 1,365 in 1872 and 686 in 1873, and the 
 mortality rates are raised correspondingly to 479 and 235, respectively. 
 
 Data for the calculation of morbidity rates and case-fatality rates in the 
 city are unfortunately lacking. The commissioner of health, writing 10 years 
 later, stated that in this epidemic, without compulsory reporting, 4,000 cases 
 of small-pox were discovered and probably as many again were- concealed; 6,000 
 cases would therefore be a conservative estimate. According to the report of 
 the physician at the Marine Hospital, the case-fatality rate was 63 per cent 
 among the unvaccinated, and 14 per cent among those who had been vaccinated. 
 Only 3 deaths occurred among individuals having “good” vaccination marks. 
 The total case-mortality rate for all ages was 40 per cent in 1872 and 42 per 
 cent in 1873. He calculated the case-mortality rates as affected by age for 
 both years. As the results are almost identical, those for 1872 are given in 
 table 38. 
 
 The high fatality-rate among the hospital cases was attributed to five sets 
 of causes: Distant transportation over rough roads, the moribund condition 
 of many patients on arrival, the preponderance of negroes, the high proportion 
 of persons of the poorest conditions of life, and the imperfection of the 
 accommodations provided. The majority of the patients had never been vacci- 
 
 Table 38. 
 
 p. c. 
 
 Under 10 years. 48 
 
 10 to 19 years. 35 
 
 20 to 29 years.38 
 
 30 to 39 years. 43 
 
 40 to 49 years. 35 
 
 50 to 59 years. 52 
 
 60 to 69 years. 66 
 
 70 to 79 years. 60 
 
 nated; a large number said they had “ been vaccinated, but it never took ”; and 
 a third class, in whom the disease was lightest, were those who had been vac¬ 
 cinated successfully in childhood. Those with good and recent vaccination scars 
 did not have the disease severely enough to confine them to bed. The favorable 
 effect of a previous attack of small-pox and of previous successful vaccination 
 upon the fatality-rate is shown by the low fatality-rates in varioloid, 2 per cent, 
 and in the previously vaccinated, 14 per cent. 
 
 The campaign of the health department, organized in March 1872, embraced 
 (1) the reporting each morning by every policeman to his district station of 
 the cases discovered on his beat; (2) the prompt investigation by a medical 
 officer of the health department detailed to each of the four police stations of 
 the new cases reported in the district; (3) the employment of the sanitary 
 inspectors to dispatch all cases willing to submit to it to the Marine Hospital, 
 to establish isolation in the homes of cases not so disposed of and in those of 
 all contacts, and to supervise disinfection of houses, clothing, and furniture; 
 and (4) the vaccination by the regular vaccine physicians of everyone who 
 would submit, whether previously vaccinated or not, dwelling or working in 
 the immediate neighborhood of reported cases. When, despite these efforts, 
 the disease continued to make rapid headway, a number of extra vaccine 
 physicians were ordered to enter each house in the city, and, “baring every 
 arm, to vaccinate everyone without unmistakable evidence of thorough protec- 
 
FEBRILE DISEASES 
 
 287 
 
 tive vaccination,” whom they could persuade or bluff into permitting it. This 
 group of vaccinators are reported to have made in these two months 33,911 
 separate calls and 11,866 vaccinations, of which 2,536 w T ere primary, 9,075 were 
 secondary, and 255 unclassified. The regular vaccine physicians were credited 
 between November 1, 1871, and October 31, 1872, with 49,028 calls and 38,784 
 vaccinations, of which 10,065 were primary, 28,240 were secondary, and 479 
 unclassified. So in this period, covering the first 12 months of the epidemic, 
 public vaccinators visited 82,939 dwellings and performed 50,650 vaccinations, 
 of which 12,601 were primary, i. e., in persons never before vaccinated; 37,315 
 were secondary, i. e., in persons who had been vaccinated previously; and 734 
 w r ere not classified. Of a total of 19,356 vaccinations inquired into for success 
 or failure, 14,045 were recorded as successful. With the marked increase of 
 the disease in January 1873, the intensive campaign of vaccination w r as renewed, 
 and for the next 6 months a corps of 80 physicians assisted the regular vaccine 
 physicians. Between November 1, 1872, and October 31, 1873, but for the 
 most part between January and July 1873, these two groups made 96,693 calls, 
 with 87,739 vaccinations, of which 7,330 were classed as primary and 80,409 
 as secondary. Thus, during this period of Baltimore’s greatest epidemic of 
 small-pox, the 20 months between November 1871 and July 1873, inclusive, 
 there were made by public vaccinators 179,632 calls, 138,389 vaccinations, 
 of which 19,931 were classified as primary and 117,724 as secondary. In other 
 words, the calls w r ere in proportion of nearly 4 to each family, the vaccinations 
 nearly 1 for each 2 persons in the population, and about one-sixth of the vaccina¬ 
 tions were primary and five-sixths secondary. 
 
 It is not improbable that many of the secondary vaccinations were in individ¬ 
 uals who had been inoculated with vaccine material but not successfully, some 
 in childhood and others since, and even during the epidemic, and are therefore 
 not to be considered as true revaccinations, i. e., vaccinations of persons who 
 had previously undergone successful vaccination. From these figures it would 
 appear that somewhat less than half the individuals of the average population 
 for these two years (138,000 out of 287,000) were accounted unprotected by 
 previous vaccination, and that of these nearly 20,000, or about 7 per cent, had 
 never been vaccinated. 
 
 Early in the epidemic it was determined that the virus furnished by the State 
 was not potent, and new virus was obtained from other sources. It is known 
 that many of the vaccinations were made with “ crusts,” which, in the opinion 
 of the commissioner of health, were often not so cut that the virus would be 
 properly applied. To what extent vaccination was carried on by private physi¬ 
 cians is not known, but it is not unlikely that the number covered a large 
 proportion of those found with satisfactory vaccination marks. A factor that 
 militated against frequency of private vaccinations even among a considerable 
 proportion of the more intelligent and better-to-do portion of the population 
 was the fact that a large moiety of the special vaccine physicians were men of 
 prominence, to whom their regular patients would have applied had they not 
 received the same services from them in their public capacity. By the end of this 
 epidemic, all but a small proportion of the population had been submitted to 
 vaccination. 
 
 During the years 1874 to 1880, the city was almost free from small-pox. 
 Though there was a death from the disease in 4 of the 7 years, it showed no 
 
288 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 tendency to spread. In 1881, small-pox was credited with 1 death in May and 
 another in June, after which the disease apparently died out. It reappeared 
 in November, causing 5 deaths each in this month and in December, and this 
 marked the beginning of a severe epidemic that lasted until July 1883. Between 
 January 1882, and the latter date there were reported 4,939 cases and 1,184 
 deaths within the city, and to these there are to be added the 359 deaths among 
 the 1.053 patients sent from the city to the Marine Hospital during the 
 epidemic. Through the 13 months from January 1882, as is strikingly shown 
 in tables 31 and 39, the disease grew in incidence and in fatality in steady 
 and almost uninterrupted progression, apparently uninfluenced by season or 
 by vaccination. The curves for morbidity and mortality would correspond even 
 more closely were it possible to add the deaths occurring at the hospital properly 
 distributed as to date of occurrence. After January 1883, the descent of the 
 
 Table 39. —Monthly morbidity and mortality, and respective rates, per 100,000 living 
 inhabitants, from small-pox, during the epidemic, 1882-1883. 
 
 O = cases. D = death. It = rate. 
 
 
 1S82 
 
 1883 
 
 C 
 
 R 
 
 D 
 
 R 
 
 C 
 
 R 
 
 D 
 
 R 
 
 Jan. 
 
 46 
 
 154 
 
 2 
 
 7 
 
 1259 
 
 4119 
 
 329 
 
 1076 
 
 Feb. 
 
 53 
 
 196 
 
 6 
 
 22 
 
 542 
 
 1964 
 
 194 
 
 703 
 
 Mar. 
 
 38 
 
 127 
 
 10 
 
 33 
 
 175 
 
 573 
 
 65 
 
 213 
 
 Apr. 
 
 78 
 
 269 
 
 12 
 
 41 
 
 92 
 
 311 
 
 28 
 
 95 
 
 May . 
 
 107 
 
 357 
 
 17 
 
 57 
 
 35 
 
 115 
 
 12 
 
 39 
 
 June . 
 
 106 
 
 366 
 
 13 
 
 45 
 
 9 
 
 30 
 
 4 
 
 14 
 
 July . 
 
 114 
 
 381 
 
 22 
 
 73 
 
 2 
 
 7 
 
 1 
 
 3 
 
 Aug. 
 
 237 
 
 791 
 
 24 
 
 80 
 
 
 • • • • 
 
 
 
 Sept. 
 
 255 
 
 880 
 
 71 
 
 245 
 
 
 • • • • 
 
 
 
 Oct. 
 
 362 
 
 1209 
 
 63 
 
 210 
 
 
 » • • • 
 
 
 
 Nov. 
 
 483 
 
 1666 
 
 94 
 
 324 
 
 
 * • • • 
 
 
 
 Dec. 
 
 946 
 
 3158 
 
 217 
 
 724 
 
 
 .... 
 
 
 
 Total . 
 
 2825 
 
 801 
 
 551 
 
 156 
 
 2114 
 
 587 
 
 633 
 
 176 
 
 curves is rapid, such as would have occurred had the disease used up its available 
 material or had its progress been checked by definite interference. It is evident 
 that this epidemic was by no means so severe as that of 1872-1873 as expressed 
 in death-rates. 
 
 This epidemic was fought by the same commissioner of health and, with two 
 important additions, with the same means and methods. The only differences 
 were that in October 1882 small-pox was made reportable, and the commissioner 
 of health was given broad powers to enforce vaccination and revaccination, 
 to compel isolation and hospitalization of those sick with small-pox, to control 
 funerals, to restrict the use of public vehicles, and to disinfect dwellings, 
 furniture, and clothing. Only 8 years before a very general vaccination, which 
 must have embraced at least two-thirds of the population, had been practiced, 
 and under the influence of the slight outbreak of small-pox in May and June 
 and the reappearance of the disease in November and December 1881, vaccina¬ 
 tion, as is shown by the decided rise in the vaccination-rate, was stimulated. 
 
FEBRILE DISEASES 
 
 289 
 
 In March 1882, and after the epidemic was well under way, the commissioner 
 of health started his force of regular vaccine physicians, now increased to 17 
 in number, on house-to-house visits in accordance with the established custom 
 to vaccinate and revaccinate those who would submit. Apparently unaffected 
 by the measures employed or by the season, the number of cases and deaths 
 continuing to mount, 52 extra vaccine physicians were employed in August and 
 September. The slight lag in the curves of morbidity and mortality in October 
 may be taken to reflect some restraining influence attributable to this activity, 
 but such, if present, was only temporary. The extra vaccine physicians were 
 called into action again in December, now with compulsory powers. In the 
 calendar year the regular vaccine physicians were credited with 40,226 calls and 
 53,290 vaccinations, of which 13,553 were primary and 39,737 were secondary. 
 Of these vaccinations, 15,954 were in colored and 37,336, in whites, or in a 
 proportion of nearly 1 to 2 where the proportion of colored to white in the 
 population was 1 to 5.5. Of 20,935 vaccinations investigated as to success or 
 failure, 15,528 were recorded as successful. The extra vaccine physicians per¬ 
 formed 41,403 vaccinations, of which 4,652 were primary. In January 1883, 
 previous efforts having failed to check the disease, 50 additional vaccine physi¬ 
 cians were appointed, making 119 vaccine physicians, all under the charge of 
 Dr. I. E. Atkinson, as supervisor of vaccinations. Furnished with a new supply 
 of the “ purest animal virus, the large force of physicians was massed in those 
 localities where the disease prevailed to the greatest extent, visiting every house 
 consecutively, baring every arm, and vaccinating and revaccinating everyone, 
 old and young, that did not present unmistakable evidence of recent, thorough, 
 and protective vaccination.” This time, under the direction of a talented and 
 trained clinician, fearless and determined, fortified now with the requisite 
 legal powers, vaccinations were performed nolens, volens. When by March there 
 was a marked diminution of the numbers of reported cases and deaths, two- 
 thirds of the extra force was discharged. The spread of the disease declined 
 rapidly and the last case was discharged in July. In this year, and chiefly 
 during the first 6 months, the regular vaccine physicians performed 26,673 
 vaccinations, 2,628 of which were primary and 24,045 were secondary, while 
 the extra vaccine physicians performed 190,377 vaccinations, of which 15,236 
 were primary and 175,141 were secondary. 
 
 Some idea of the extent of vaccination in the city at this time is conveyed by 
 the following figures: In a total population of 352,674, the public vaccinators, 
 regular and extra, vaccinated between January 1, 1882, and July 1, 1883, 
 some 311,743 persons (or the whole population with the exception of 40,931), 
 and of these, 38,697 were primary and 273,046 were secondary vaccinations. 
 A large proportion of the 40,931 persons not so vaccinated were presumably 
 passed by the public vaccinators because they had been recently vaccinated 
 successfully by private physicians. Therefore, disregarding these, only about 12 
 per cent of the 311,743 persons covered by the records had never been vaccinated. 
 So it would appear that at that time vaccination had been so widely practiced 
 that between 85 and 90 per cent of the population had been submitted to appar¬ 
 ently successful vaccination. Of the 79,963 vaccinations (16,181 primary, and 
 63,782 secondary) performed by the regular vaccine physicians, 28,847 were 
 investigated as to success or failure, and of these 21,930 were recorded as 
 successful and 6,917 as unsuccessful, whence it would appear that if all the 
 
290 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 primary vaccinations be granted to be successful, 5,749 of the 63,782 secondary 
 vaccinations, or about 9 per cent, “took” and consequently something like 10 
 per cent of the previously vaccinated members of the population were susceptible 
 to small-pox on exposure. Now, of the 4,939 cases of small-pox reported during 
 this epidemic, 2,858, or about 58 per cent are recorded to have occurred among 
 those previously vaccinated, and 2,081, or 42 per cent, among the unvaccinated; 
 so if the 40,000-odd persons presumably vaccinated by private physicians be 
 apportioned as unvaccinated and previously vaccinated as 1 to 7 respectively, 
 there would have been in the population approximately 43,697 persons of the 
 former and 59,574 of the latter category (arrived at as follows: Total number 
 of primary vaccinations 38,697 + 5,000 = 43,697, and 9 per cent of 273,046 = 
 24,574, and 24,574 + 35,000 = 59,574), from which it would appear that the 
 attack-rate was 6,540 per 100,000 persons among the non-vaccinated and 3,493 
 per 100,000 among persons previously vaccinated but whose immunity had 
 lapsed. Of the 2,858 cases among those previously vaccinated there was a 
 fatality of 327, or 11 per cent, and of the 2,081 cases among the non-vaccinated, 
 839, or 40 per cent, the total rate being 24 per cent. These rates for non- 
 vaccinated and for total, at least, are lower than the true rates, for in calculating 
 them the deaths occurring among those sent to the Marine Hospital were not 
 included in the tables of the commissioner of health. Including the 359 deaths 
 among the 1,053 cases sent to the Marine Hospital in 1882 and 1883, the total 
 fatalities were 1,543, with a case fatality of 31.3 per cent. During this epidemic 
 the case-fatality rate among the cases at the Marine Hospital was decidedly 
 lower than in the epidemic of 1872-1873. 
 
 Twenty years elapsed (1902) before there was a serious threat of epidemic 
 small-pox, and in only three of these years (1884, 1886, and 1899) were there 
 deaths registered against this disease in the city. In each of these years there 
 was a single death. However, there were during these 20 years numerous 
 occasions when cases were imported and the disease spread to a few contacts. 
 Such cases were almost invariably sent to the quarantine hospital and the 
 deaths among them not charged to the city. Mortality-rates averaged for 5- 
 and 10-year periods are given in table 43 (page 301) and graphs 12 and 16. 
 
 Only since 1899 are the records of reported cases given in the annual reports. 
 The morbidity reports from this date (table 40) show, however, that in but a 
 single year (1916) has the disease failed to show itself. In some years, as in 
 1902 to 1904 and in 1913 to 1914, the number of reported cases has been suffi¬ 
 cient to warrant the use of the term epidemic. 
 
 It will be noted that beginning with 1890 there was for some years a marked 
 increase in the vaccination-rates. These reached rather high levels in years of 
 actual or threatened epidemic. The State law regarding the admission of un¬ 
 vaccinated children to schools remained a dead letter until after the inaugura¬ 
 tion of school inspection in 1908. 
 
 From the monthly tables of reported cases since 1899 (table 40) and of 
 deaths from 1856 to 1914 (table 37), and the monthly annual rates calculated 
 therefrom, the influence of season on the incidence and mortality from small¬ 
 pox is clearly shown. With hardly an exception, the heaviest morbidity has 
 been in the cold months, and a characteristic of the course of the disease, when 
 present, has been a rise in incidence and death-rates during the fall to an acme 
 
FEBKILE DISEASES 
 
 291 
 
 Table 40. —Morbidity by months and years and the monthly annual and annual rates 
 of morbidity, per 100,000 living inhabitants, from small-pox, from 1897 to 1920, 
 inclusive.* 
 
 O = cases. R = rate. 
 
 
 
 
 
 Jan. 
 
 Feb. 
 
 Mar. 
 
 Apr. 
 
 May. 
 
 June. 
 
 
 July. 
 
 
 Year. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 C 
 
 R 
 
 C 
 
 R 
 
 C 
 
 R 
 
 C 
 
 R 
 
 C 
 
 R 
 
 C 
 
 R 
 
 C 
 
 R 
 
 
 1899 . 
 
 2 
 
 5 
 
 2 
 
 5 
 
 7 
 
 16 
 
 2 
 
 5 
 
 3 
 
 7 
 
 
 
 
 
 1 
 
 2 
 
 1900 . 
 
 
 
 
 
 
 9 
 
 22 
 
 2 
 
 5 
 
 
 3 
 
 7 
 
 
 1 
 
 2 
 
 1901 . 
 
 3 
 
 7 
 
 1 
 
 3 
 
 4 
 
 9 
 
 1 
 
 2 
 
 2 
 
 5 
 
 
 1 
 
 2 
 
 
 
 
 1902 . 
 
 
 
 14 
 
 35 
 
 3 
 
 7 
 
 3 
 
 7 
 
 5 
 
 11 
 
 
 
 
 
 1 
 
 2 
 
 1903 ... 
 
 
 
 
 2 
 
 4 
 
 6 
 
 15 
 
 10 
 
 22 
 
 5 
 
 12 
 
 13 
 
 29 
 
 
 1 
 
 2 
 
 
 1 
 
 2 
 
 1904 ... 
 
 
 
 
 1 
 
 2 
 
 4 
 
 10 
 
 9 
 
 20 
 
 14 
 
 32 
 
 20 
 
 44 
 
 10 
 
 23 
 
 
 • • 
 
 • • • 
 
 1905 ... 
 
 
 
 
 
 
 
 ... 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1906 ... 
 
 
 
 
 14 
 
 30 
 
 19 
 
 45 
 
 14 
 
 30 
 
 9 
 
 20 
 
 2 
 
 4 
 
 
 
 
 
 
 
 1907 ... 
 
 
 
 
 
 
 2 
 
 5 
 
 
 
 
 
 
 
 
 1 
 
 2 
 
 
 
 
 1908 ... 
 
 
 
 
 1 
 
 2 
 
 2 
 
 5 
 
 • • • 
 
 • • • 
 
 1 
 
 2 
 
 1 
 
 2 
 
 • • 
 
 • 
 
 
 
 1 
 
 2 
 
 1909 ... 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1910 ... 
 
 
 
 
 
 
 
 
 1 
 
 2 
 
 1 
 
 2 
 
 
 
 
 
 
 
 
 
 1911 . 
 
 
 
 
 
 1 
 
 2 
 
 
 
 
 
 
 
 
 
 1912 ... 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1913 ... 
 
 
 
 
 27 
 
 54 
 
 13 
 
 287 
 
 1 
 
 2 
 
 • • • 
 
 • • • 
 
 2 
 
 4 
 
 
 1 
 
 2 
 
 
 2 
 
 4 
 
 1914 ... 
 
 
 
 
 29 
 
 57 
 
 82 
 
 179 
 
 143 
 
 283 
 
 44 
 
 90 
 
 15 
 
 30 
 
 11 
 
 22 
 
 
 1 
 
 2 
 
 1915 ... 
 
 
 
 
 
 
 
 
 12 
 
 23 
 
 
 
 
 
 
 
 
 
 
 
 1917 . 
 
 
 
 2 
 
 4 
 
 7 
 
 13 
 
 3 
 
 6 
 
 
 
 
 
 
 
 1918 ... 
 
 
 
 
 7 
 
 13 
 
 5 
 
 11 
 
 10 
 
 19 
 
 10 
 
 20 
 
 9 
 
 17 
 
 
 5 
 
 10 
 
 
 # # 
 
 • • • 
 
 1919 ... 
 
 
 
 
 
 
 1 
 
 2 
 
 9 
 
 15 
 
 4 
 
 7 
 
 3 
 
 5 
 
 
 
 
 
 1 
 
 2 
 
 1920 . 
 
 4 
 
 6 
 
 5 
 
 9 
 
 2 
 
 3 
 
 10 
 
 17 
 
 6 
 
 10 
 
 
 4 
 
 7 
 
 
 1 
 
 2 
 
 
 Aug. 
 
 Sept. 
 
 Oct. 
 
 Nov. 
 
 Dec. 
 
 Total. 
 
 Per cent, 
 case fatality. 
 
 Year. 
 
 C 
 
 R 
 
 C 
 
 R 
 
 C 
 
 1 
 
 R 
 
 C 
 
 R 
 
 C 
 
 R 
 
 C 
 
 R 
 
 Average 
 rate of 
 morbid¬ 
 ity by 
 5-year 
 periods. 
 
 Annual. 
 
 Aver¬ 
 age by 
 5-year 
 periods 
 
 1899 .. 
 
 
 
 
 
 
 
 
 
 1 
 
 2 
 
 18 
 
 4 
 
 
 
 6 
 
 
 
 1900 
 
 1 
 
 2 
 
 
 
 
 
 
 
 1 
 
 2 
 
 17 
 
 3 
 
 2 
 
 
 
 
 
 1 
 
 1901 .. 
 
 
 
 
 
 
 1 
 
 2 
 
 1 
 
 2 
 
 14 
 
 3 
 
 
 
 
 
 
 
 
 1902 .. 
 
 
 
 2 
 
 5 
 
 
 
 
 
 1 
 
 2 
 
 29 
 
 6 
 
 
 
 24 
 
 
 
 1903 .. 
 
 1904 .. 
 
 
 
 1 
 
 2 
 
 1 
 
 2 
 
 
 
 1 
 
 2 
 
 41 
 
 8 
 
 
 9 
 
 5 
 
 
 
 
 
 
 
 
 
 
 
 
 
 58 
 
 11 
 
 
 
 7 
 
 
 
 1905 .. 
 
 
 
 
 
 
 
 3 
 
 7 
 
 19 
 
 41 
 
 22 
 
 4 
 
 6 
 
 
 
 
 
 7 
 
 1906 .. 
 
 
 
 
 
 
 
 
 
 58 
 
 11 
 
 
 
 
 
 
 1907 .. 
 
 
 
 
 
 
 
 
 
 1 
 
 2 
 
 4 
 
 1 
 
 
 
 
 1908 .. 
 
 
 
 
 
 
 
 
 
 
 
 6 
 
 1 
 
 
 
 
 1909 .. 
 
 
 
 
 
 
 
 
 
 2 
 
 4 
 
 2 
 
 
 
 
 
 1910 .. 
 
 
 
 
 
 
 
 
 
 
 
 2 
 
 
 3 
 
 
 
 
 1911 .. 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 
 
 
 
 
 1912 
 
 
 
 
 
 
 
 4 
 
 8 
 
 11 
 
 22 
 
 15 
 
 3 
 
 
 
 
 1913 .. 
 
 
 
 3 
 
 6 
 
 
 
 
 1 
 
 2 
 
 50 
 
 8 
 
 
 
 
 1914 .. 
 
 
 
 
 
 
 
 
 
 
 325 
 
 55 
 
 
 
 1 
 
 
 
 1915 .. 
 
 
 
 
 
 
 
 
 
 
 
 12 
 
 2 
 
 14 
 
 
 
 
 
 1917 .. 
 
 
 
 
 
 
 
 1 
 
 2 
 
 10 
 
 19 
 
 23 
 
 38 
 
 
 
 1918 .. 
 
 
 
 
 
 
 
 
 
 46 
 
 7 
 
 
 
 
 1919 .. 
 
 
 
 
 
 
 
 
 
 
 
 18 
 
 3 
 
 
 
 
 1920 .. 
 
 2 
 
 3 
 
 
 
 
 
 
 
 
 
 34 
 
 5 
 
 10 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 * Those years in which cases did not occur have been omitted from this table. 
 
292 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 in the winter or spring, followed by a decline to a low point, even to complete 
 disappearance, during the hot weather. 
 
 The well-known association of increase in the spread and virulence of small¬ 
 pox with w^ars suggests examination of the recorded experience of Baltimore in 
 this connection. For this purpose it will be convenient to compare the time 
 relationships of the chief local epidemic outbreaks with the occurrence of wars 
 in America and elsewhere. The epidemic of 1811 to 1812 coincides with the 
 Napoleonic wars in Europe, and the last year with the first year of the Anglo- 
 American War of 1812-1815. No great war w y as being waged in Europe or 
 America just previous to 1821. The uprising in Europe in connection with 
 Belgium and the beginning of the struggle of Italy for freedom correspond 
 
 Graph 12 (from table 43). Crude mortality rates from small-pox, varicella, 
 and influenza, averaged by 5-year periods, from 1812 to 1920, inclusive. 
 
 with the outbreak of small-pox in 1831-1834, and the Italo-Austrian struggle 
 may be cited in relation to that of 1837-1838. The epidemic of 1845-1846 
 preceded our war with Mexico; that of 1849-1852 followed closely it and the 
 disturbances in Europe in 1848; and the epidemics of 1854-1855 and 1857- 
 1858 occurred shortly after the Crimean War and the accentuation of the 
 Italian struggle. There was a distinct coincidence between the epidemics of 
 1862-1865 and 1871-1873, and the American Civil and the Franco-Prussian 
 Wars, respectively. The great outbreak of 1881-1883 may possibly have been 
 related to increased prevalence of small-pox in association with the Russo- 
 Turkish War, and the Balkan troubles and the British attack on Egypt, and 
 it is likewise possible that there was a relationship between the slight epidemic 
 of 1902-1904, and 1912-1914 with the Spanish-American War of 1898 and 
 the Anglo-Boer War of 1899-1902, and the Balkan Wars of 1912. 
 
FEBRILE DISEASES 
 
 293 
 
 However, the coincidence in time between two events is only suggestive and 
 falls far short of proof that one holds a causal relationship to the other. There 
 is little doubt that the Napoleonic Wars were responsible for spreading small¬ 
 pox over central Europe and thence to America, that small-pox in virulent form 
 spread widely in Europe and in America during and after the Franco-Prussian 
 War, and that in both instances the troops were primarily responsible for spread 
 of this disease. That there was considerable small-pox for a time in the Ameri¬ 
 can Civil War and that Baltimore was favorably situated for infection is true, 
 and it is very likely that the local epidemic of that time, in some measure at 
 least, was of this origin. However, until the last two decades of the nineteenth 
 century, small-pox was prevalent in many countries in Europe, and particularly 
 those countries from which immigrants come to Baltimore; and furthermore, 
 Europe was rarely entirely free from war. 
 
 The history of small-pox in Baltimore presents some striking features from 
 which may be drawn instructive information in regard to the natural history 
 of the disease and valuable lessons in public-health administration. The first 
 concerns the endemic and epidemic states of the disease in the community. 
 While it is true that, unlike other members of the group, from the earliest 
 times its natural course has been modified by artificial interferences with its 
 entrance and spread in the city, enough is known of the value of these at differ¬ 
 ent periods to allow for their discount with some measure of certainty. Between 
 1800 and 1830, when the use of inoculation and of vaccination were compara¬ 
 tively restricted and quarantine and general methods designed to prevent its 
 spread among the inhabitants were of the most meager sort, the disease occurred 
 repeatedly in small and twice in large outbreaks without becoming endemically 
 established. On the other hand, between 1831 and 1866, in association with 
 much wider use of vaccination and of restrictive measures of a general sort, 
 small-pox was very commonly, if not constantly endemic. During this period 
 upon this endemic state there were imposed a number of periodic epidemic 
 waves, which were not usually associated with mortality rates as high for 
 individual years as were those experienced before and later. Between 1867 
 and 1883 this phase was succeeded by a return to the conditions prevailing 
 before 1830, when the disease was no longer endemically established, but 
 appeared only from time to time, with two very serious epidemics (1872-1873 
 and 1882-1883) separated by an interval of 10 years. 
 
 These two epidemic visitations, with mortality rates, when proper allow¬ 
 ances for deaths occurring at the small-pox hospital are made, much higher 
 than ever before experienced, occurred after a period of increased public vacci¬ 
 nation-rates, the establishment of a State vaccine institution for the propagation 
 of potent virus, the passage of State laws requiring compulsory vaccination of 
 infants, and the exclusion of unvaccinated children from school. As neither 
 of these legal provisions was systematically obeyed (the commissioner of health 
 discarded the State virus as impotent in 1872), any effects which would in 
 theory be credited to them must be largely discounted in practice. However, 
 in spite of these activities as planned and executed and of the most active and 
 widespread vaccination campaigns ever conducted in the city, these two epi¬ 
 demics lasted for the usual period of 18 or 20 months and, relative to the 
 population, were even severer in degree than any of their predecessors. 
 
294 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 Since 1884, small-pox has taken on a new phase, one which is without parallel 
 in previous experience. Though introduced many times, and since 1897 
 present each year, the disease has not acquired endemic status and has only 
 twice (1902-1904 and 1912-1914) threatened to become seriously epidemic. 
 While, owing to the fact that most of those ill of the disease have of late years 
 been removed to quarantine hospitals without the city, the deaths officially 
 credited to small-pox by no means represent the actual fatality; nevertheless, 
 the number has been small, and in comparison with earlier periods almost 
 negligible. During this period vaccination has increased, virus has been greatly 
 improved, and case-reporting and isolation have been secured. Another factor 
 of considerable importance is that since 1884 the bulk of the European immi¬ 
 grants has come from countries where vaccination was enforced, while previous 
 to this date the contrary was the case. Since 1900, at least, the disease has 
 been introduced almost entirely by negroes from the South, and has been 
 largely confined to this race. 
 
 It is of considerable interest that severe epidemic outbreaks have tended to 
 occur at about 10-year intervals falling at or near the beginning of decennia, 
 as in 1811, 1821, 1831, 1850, 1862, 1872, 1882, 1902, and 1912. 
 
 It seems clear that until 1884 the prevalence and mortality of small-pox 
 were governed to a much greater degree by its inherent natural characteristics 
 in their relation to the population, than by any artificial interferences, including 
 vaccination, that were interposed. It appears that before 1900 the course of the 
 disease could have been only modified and not controlled by vaccination as 
 practiced. 
 
 When the curves of the rates for small-pox mortality and public vaccination 
 incidence are compared, it is evident that, as a rule to which there are striking 
 exceptions, vaccination was considerably stimulated by the unusual presence 
 of small-pox. 
 
 The want of perception on the part of the people in withholding from the 
 health department powers which experience had repeatedly shown to be neces¬ 
 sary for adequate protection against small-pox is one of the most important 
 features in the public-health history of Baltimore. Though almost always under 
 the shadow of this dread disease and frequently experiencing severe epidemics, 
 and with ample evidence that the voluntary system was a failure, it was only 
 by gradual stages that the compulsory system was adopted. Not until 1882 
 was the commissioner of health given the powers demanded as essential by 
 Dr. Jameson in 1832, and not until 30 years later was vaccination generally 
 enforced to a point of reasonable but still far short of perfect security against 
 small-pox. As a matter of fact, it was not until over 100 years after the dis¬ 
 covery of vaccination and the introduction of the method in Baltimore that it 
 was given a test even approximately fair. 
 
 The proposal in 1820 to make small-pox cases compulsorily reportable was 
 successfully restrained by the physicians, and this evidently reasonable pro¬ 
 cedure was postponed until 1882. 
 
 Hardly less reprehensible was the inhuman treatment of the poor victims of 
 small-pox who were dragged in rough wagons over rougher roads in all weathers 
 to the “ Marine Hospital,” which, according to the mistaken idea of the times, 
 was situated in the most inaccessible of places. It is no wonder that some 
 
FEBRILE DISEASES 
 
 295 
 
 perished on the way and that many were moribund on arrival. Less barbarous, 
 but equally unnecessary, has been the later custom still in vogue of transporting 
 small-pox patients by water to the present quarantine station, where the accom¬ 
 modations furnished by the city can scarcely be dignified by the term hospital. 
 
 It will be understood that, before 1827, the vaccinations performed by the 
 public vaccinators represented only those made on the poor who desired it, 
 but were unable to pay the modest charges demanded by private physicians. 
 In this year and until 1882, in addition to these were included the compulsory 
 vaccinations of those in the immediate neighborhood of known, cases of small¬ 
 pox. After the great campaign of compulsory vaccinations in 1882-1883, the 
 services of the public vaccinators were available to all who might apply, and 
 the vaccine physicians have kept special office hours for the purpose. These 
 services of late years, especially since the system of school inspection has made 
 it possible to compel vaccination of all school children, have been widely 
 accepted. With the exception of special drives now and then directed against 
 known contacts with small-pox cases, this is the only compulsion now exercised 
 over vaccination. Since granted the power in 1882, the commissioners of 
 health have but rarely ordered vaccination and revaccination. The State law 
 regarding the vaccination of infants in their first year of age has been and is a 
 dead letter. 
 
 Concerning the question of vaccinations by private physicians, it is safe to 
 say that probably by 1814, and certainly by 1821, in the bulk of the well-to-do 
 families in the clientele of physicians of the better type, the children were 
 routinely vaccinated in infancy, and in many cases revaccination was practiced 
 at puberty, and often later in life, particularly in times of small-pox epidemics, 
 which were abundant enough until after 1884. Among such people there has 
 probably been but little neglect in this regard, and they have passed safely 
 through the various epidemics. Among the whites, it has been the newest immi¬ 
 grant who has neglected to protect himself and his family. This was particu¬ 
 larly marked in the Irish and German immigrants, who were unaccustomed to 
 general vaccination at home. The Bohemians, among more recent immigrants, 
 were unfamiliar with vaccination. Among the Poles and Polish Jews vaccina¬ 
 tion was common, and the latter regularly present their children for vaccina¬ 
 tion in May. Doubtless the slave negroes were commonly vaccinated. But 
 above all, it has been the free negro, both before and since the Civil War, 
 who has contributed the largest quota to the army of the unvaccinated. Among 
 these, those in domestic service have in the main accepted vaccination, partly 
 from example and partly because employers demanded it. A third but relatively 
 small group, composed of white persons of native birth from other States, in 
 many other respects apparently rational, have avoided vaccination for their 
 children and themselves on various grounds. Eeports of the school inspectors 
 showed in 1911 but 5 per cent and in 1918 less than 1 per cent of the children 
 in the public and parochial schools had not been successfully vaccinated. 
 
 “ Crusts ” were much in vogue as late as 1872 and were employed to some 
 degree until much later. Smith’s virus was probably in continuous use for many 
 years. The health department’s virus, the dependence of the vaccine physicians 
 and probably collected by them, was jealously guarded and was freely dispensed. 
 In 1832, 1843, and 1846 it was “ renewed ” by passage through the cow. The 
 
296 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 State’s virus was discarded as impotent by the health department in 1872, and 
 since that date the city health department has purchased virus from commercial 
 firms. The large proportion of the cases of small-pox, G8 per cent, reported by 
 the physicians in charge at the Marine Hospital as occurring in 1872 among the 
 previously vaccinated, and with considerable but relatively low fatalities as 
 compared with the unvaccinated, attests to previous use of virus of low potency. 
 Prior to 1904, when the Public Health Service undertook supervision of com¬ 
 mercial virus, much of this was perhaps either impotent or at least of poor 
 grade. As the results were under the constant observation of the vaccine physi¬ 
 cians, however, who would report poor virus, it was probably usually superior 
 to the virus purchased through most druggists. Of late years the health depart¬ 
 ment has dispensed in large quantities freely to physicians a pure and highly 1 
 potent vaccine virus purchased by contract from commercial firms. 
 
 CHICKEN-POX. 
 
 Just when chicken-pox was first introduced into Baltimore and when it 
 became endemic is not known. No deaths were recorded before 1821, and cases 
 were not reported routinely until 1897. There is every reason to think that 
 varicella has been prevalent since at least the beginning of the nineteenth 
 century. Judging from the annual mortality rates (table 34, graph 11), it 
 was somewhat more fatal in the earlier years than in the recent years embraced 
 in the records, but at no time has it contributed significantly to the lists of 
 deaths. From the morbidity reports since 1897 (table 41), it would appear 
 that this disease has become progressively more prevalent, and it might be 
 argued with some reason that it runs in waves of incidence like others of this 
 group. Because of the probability of confusion in diagnosis between small-pox 
 and chicken-pox, the almost constant presence of the former during this period 
 has stimulated the reporting of cases of the latter when seen by physicians. 
 However, varicella is so mild that in many cases physicians are not summoned, 
 and to the ignorant even small-pox is not a menace. Much more likely is it 
 that the increase in the morbidity of chicken-pox is due, in largest part at 
 least, to more accurate reporting of cases during the past 10 years, under the 
 pressure exercised by the health department. In this connection it may be 
 pointed out that the morbidity-rates do not indicate that the efforts made dur¬ 
 ing this period to restrict the spread of this disease have affected its course. 
 
 The monthly annual morbidity-rates (table 41) indicate very clearly the 
 influence of season upon the prevalence of the disease. From the midsummer 
 low point, usually August, but in some years July and in others September, the 
 wave of incidence commonly ascends smoothly to a peak reached in January 
 or February and declines in much the same gradual manner during the succeed¬ 
 ing months to complete the 12-month cycle. Whether the number of cases 
 reported is greater or smaller, the same relative distribution to season is con¬ 
 stantly repeated. Previous to 1921, there are no data for determining the 
 influence of race, sex, and age upon the incidence of this disease. Rates specific 
 for these categories in this year are presented in table 42. It will be noted 
 that of the total of 1,938 cases, 1,700 were in individuals below the tenth year 
 of age, and that the rate in the second was double that in the first five years 
 of life. During the first year of life, when the rates were relatively low, there 
 
Table 41. —Morbidity by months and years and the monthly annual and annual rates of morbidity, per 100,000 living inhabitants, from varicella, 
 
 from 1897 to 1920, inclusive. 
 
 FEBRILE DISEASES 
 
 297 
 
 
 
 
 
 0 
 
 no r- 
 
 00 
 
 05 
 
 Xt 
 
 05 
 
 co co 
 
 CO 
 
 5(0 
 
 05 
 
 C5 
 
 CO 
 
 CO 
 
 xt 1—1 05 lx- 
 
 Xt 
 
 fx 
 
 C5 
 
 no no 
 
 
 
 
 Cm 
 
 rH 
 
 Of 
 
 CO 
 
 CO 
 
 CO 
 
 HI 
 
 x* 
 
 co 
 
 Xt 
 
 CO 
 
 no 
 
 O- 
 
 r- 
 
 CO 
 
 CO 
 
 00 0 
 
 CO Of 
 
 no 
 
 05 
 
 O 
 
 tx 
 
 C5 
 
 r-x 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 rH 
 
 rH rH 
 
 rH 
 
 Of 
 
 
 rH 
 
 rH 
 
 O 
 
 
 
 
 tx 
 
 xt 
 
 CO 
 
 0-5 
 
 C5 
 
 
 CO 
 
 xt 
 
 x* 
 
 »o 
 
 CO 
 
 CO 
 
 no 
 
 0 
 
 50 
 
 00 »o 
 
 00 xt 
 
 no 
 
 O 
 
 xt 
 
 05 
 
 xt 
 
 Eh 
 
 
 
 0 
 
 Xt 
 
 Of 
 
 00 
 
 C5 
 
 05 
 
 CO 
 
 no 
 
 CO 
 
 CO 
 
 C5 
 
 0 
 
 0 
 
 xt 
 
 CO 
 
 05 
 
 00 05 
 
 00 CO 
 
 co 
 
 C5 
 
 rH 
 
 no 
 
 CO 
 
 
 
 
 
 rH 
 
 rH 
 
 rH 
 
 rH 
 
 05 
 
 05 
 
 00 
 
 05 
 
 rH 
 
 co 
 
 Xf 
 
 xt 
 
 CO 
 
 X* 
 
 xt 50 
 
 tx fx 
 
 05 
 
 CO 
 
 CO 
 
 Of 
 
 xt 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 rH 
 
 
 rH 
 
 rH 
 
 
 
 
 
 05 
 
 10 
 
 rH 
 
 rH 
 
 00 
 
 OO 
 
 CO 
 
 CO 
 
 O 
 
 xt 
 
 x+l 
 
 05 
 
 tx 
 
 rH 
 
 no 
 
 CO CO 
 
 tx xt 
 
 05 
 
 no 
 
 CO 
 
 00 
 
 xt 
 
 
 
 
 05 
 
 of 
 
 no 
 
 no 
 
 10 
 
 0 
 
 00 
 
 CO 
 
 05 
 
 50 
 
 50 CO lx- 
 
 CO 
 
 0 
 
 CD 
 
 X* xtl 
 
 05 CO 
 
 xt 
 
 co 
 
 00 
 
 05 
 
 0 
 
 Dec. 
 
 
 
 
 
 
 rH 
 
 
 rH 
 
 
 rH 
 
 rH 
 
 
 
 rH 
 
 rH 
 
 rH 
 
 rH 
 
 05 
 
 rH rH 
 
 05 05 
 
 rH 
 
 no 
 
 
 CO 
 
 xt 
 
 
 
 O 
 
 C5 
 
 CO 
 
 Xt 
 
 05 
 
 tx 
 
 05 
 
 rH 
 
 tx 
 
 CO 
 
 no 
 
 CO 
 
 50 
 
 CO 
 
 05 
 
 O 
 
 H CO 
 
 no no 
 
 CO 
 
 Xt 
 
 no 
 
 xt 
 
 05 
 
 
 
 
 rH 
 
 05 
 
 CO 
 
 05 
 
 Xt 
 
 CO 
 
 CO 
 
 50 
 
 05 
 
 05 
 
 CO 
 
 GO 
 
 CO 
 
 xjH 
 
 CO 
 
 tx f x 
 
 1—1 CO 
 
 tx 
 
 0 
 
 xt 
 
 xt 
 
 no 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 rH 
 
 
 rH rH 
 
 
 Of 
 
 
 Of 
 
 05 
 
 
 
 
 05 
 
 00 xt 
 
 00 
 
 »C0 
 
 O 
 
 O 
 
 co 
 
 rH 
 
 rH 
 
 xt 
 
 no 
 
 no 
 
 rH 
 
 CD 
 
 N 
 
 O fx 
 
 05 tx 
 
 xt 
 
 00 
 
 05 
 
 0 
 
 05 
 
 
 
 
 
 xt 
 
 tx 
 
 no 
 
 no 
 
 x* tx 
 
 05 
 
 xt 
 
 Xt 
 
 tx 
 
 00 tx 
 
 CO 
 
 CO 
 
 no 05 
 
 tx <M 
 
 CO 
 
 tx 
 
 CO 
 
 CO 
 
 05 
 
 > 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 rH 
 
 
 rH rH 
 
 
 CO 
 
 
 rH 
 
 rH 
 
 
 
 
 
 CO 
 
 00 
 
 05 
 
 co 
 
 rH 
 
 tx co 
 
 O 
 
 00 
 
 0 
 
 xt 
 
 05 
 
 CO 
 
 rH 
 
 no 
 
 Xt I-x 
 
 xt CO 
 
 05 
 
 0 
 
 CO 
 
 no 
 
 CO 
 
 
 
 
 O 
 
 
 rH 
 
 CO 
 
 05 
 
 05 
 
 rH CO 
 
 xt 
 
 rH 
 
 05 
 
 CO 
 
 CO 
 
 CO 
 
 co 
 
 CO 
 
 05 xt 
 
 00 CO 
 
 CO 
 
 05 
 
 rH 
 
 05 
 
 rH 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 rH 
 
 
 
 l-H 
 
 
 
 05 
 
 05 
 
 0 
 
 CO 
 
 no 
 
 CO 
 
 no 
 
 no r- 
 
 fx 
 
 05 
 
 05 
 
 CO 
 
 no 
 
 05 
 
 no 
 
 O CO 
 
 O tx 
 
 05 
 
 CO 
 
 CO 
 
 05 
 
 tx 
 
 
 
 
 rH 
 
 rH 
 
 
 rH 
 
 
 05 
 
 CO 
 
 
 
 rH 
 
 X* 
 
 rH 
 
 rH CO 
 
 05 xt 
 
 Xt no 
 
 CO 
 
 05 
 
 05 
 
 CO 
 
 co 
 
 O 
 
 
 
 
 fH 
 
 xt 
 
 N 
 
 05 
 
 tx 
 
 05 
 
 rH 
 
 fx CO 
 
 xt< 
 
 05 
 
 05 t» 05 
 
 fx 
 
 O CO 
 
 O 05 
 
 0 
 
 O 
 
 05 
 
 05 
 
 05 
 
 
 
 
 O 
 
 
 
 
 
 
 
 rH 
 
 rH 
 
 
 
 
 05 
 
 
 
 rH 
 
 rH 
 
 05 05 
 
 05 
 
 no 
 
 rH 
 
 xt 
 
 xt 
 
 
 
 
 
 
 05 
 
 fx 
 
 
 s 
 
 05 
 
 rH 
 
 rH 
 
 rH 
 
 05 
 
 05 
 
 05 
 
 05 
 
 co 
 
 eo 
 
 O Xt 
 
 00 05 
 
 O 
 
 00 
 
 00 
 
 05 
 
 00 
 
 • 
 
 
 
 05 
 
 
 
 
 
 • 
 
 
 05 
 
 rH 
 
 rH 
 
 
 
 
 
 
 05 
 
 rH 
 
 CO 
 
 05 
 
 rH 
 
 
 05 
 
 Of 
 
 04 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 O 
 
 OG 
 
 
 O 
 
 
 rH 
 
 CO 
 
 
 • 
 
 xt 
 
 05 
 
 no 
 
 no 
 
 rH 
 
 rH 
 
 1 
 
 4 
 
 3 
 
 rH 
 
 5 
 
 2 
 
 xt CO 
 
 O 
 
 C5 
 
 Xt 
 
 tx 
 
 tx 
 
 
 
 
 
 
 • 
 
 
 
 
 
 
 
 
 
 
 rH 
 
 
 rH 
 
 rH 
 
 
 
 rH 
 
 rH 
 
 
 
 
 05 
 
 
 Of 
 
 C5 
 
 
 no t'- co 
 
 xt 
 
 • 
 
 CO 
 
 X* 
 
 rH 
 
 05 
 
 05 
 
 CO 
 
 O xt 
 
 OO Of 
 
 no 
 
 co 
 
 eo 
 
 00 
 
 xt 
 
 
 
 
 
 
 
 
 
 
 rH 
 
 
 • 
 
 
 
 rH 
 
 
 
 
 rH 
 
 05 
 
 co 
 
 Of 
 
 rH 
 
 rH 
 
 rH 
 
 to 
 
 3 
 
 
 
 
 
 
 
 
 
 
 
 
 • 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 O 
 
 
 rH 
 
 Xt 
 
 
 05 
 
 CO 
 
 CO 
 
 05 
 
 • 
 
 CO 
 
 05 
 
 no 
 
 rH 
 
 rH 
 
 CO 
 
 5 
 
 2 
 
 rH 
 
 00 
 
 Of 
 
 tx 
 
 rH 
 
 05 
 
 
 
 
 
 
 
 
 
 
 
 
 • 
 
 
 
 
 
 
 
 
 rH 
 
 rH 
 
 rH 
 
 
 rH 
 
 
 
 
 
 
 Of 
 
 • 
 
 tx 
 
 05 
 
 xt 
 
 50 l'- 
 
 rH 
 
 05 
 
 tx 
 
 00 N 50 
 
 0 
 
 00 
 
 CO xt 
 
 00 no 
 
 05 
 
 rH 
 
 00 
 
 tx 
 
 tx 
 
 • 
 
 
 
 05 
 
 
 • 
 
 
 rH 
 
 rH 
 
 
 CO 
 
 CO 
 
 
 rH 
 
 05 
 
 rH 
 
 rH 
 
 rH 
 
 
 05 
 
 co 
 
 CO 
 
 tx 
 
 xt 
 
 no 
 
 05 
 
 'a 
 
 
 
 
 rH 
 
 • 
 
 CO 
 
 no co 
 
 05 
 
 CO 
 
 Xt 
 
 rH 
 
 00 
 
 CO 
 
 8 
 
 7 
 
 5 
 
 xt 
 
 CO 05 
 
 xt 00 
 
 05 
 
 tx 
 
 no 
 
 no 
 
 tx 
 
 
 
 
 O 
 
 
 
 
 
 
 
 
 rH 
 
 
 
 rH 
 
 
 
 
 
 rH 
 
 rH 
 
 CO 
 
 CO 
 
 Of 
 
 co 
 
 rH 
 
 
 
 
 
 CO 
 
 0 
 
 tx 
 
 xt 
 
 tx 
 
 co 
 
 CO 
 
 00 
 
 05 
 
 rH Gi 
 
 00 
 
 xt 
 
 50 
 
 05 
 
 00 no 
 
 no no co 
 
 CO 
 
 05 
 
 no 
 
 00 
 
 
 
 
 05 
 
 
 rH 
 
 C5 
 
 rH 
 
 Xt 
 
 05 
 
 05 
 
 Xt 
 
 CO 
 
 co 
 
 
 05 
 
 05 
 
 no 
 
 x* 
 
 xt 05 
 
 no no 
 
 rH 
 
 0 
 
 co 
 
 CO 
 
 CO 
 
 6 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Of 
 
 05 
 
 
 rH 
 
 I-H 
 
 s 
 
 
 
 
 rH rji 
 
 rH 
 
 co 
 
 O 
 
 rH 
 
 O 
 
 rH 
 
 xt 
 
 xt 
 
 xt 
 
 co 
 
 rH 
 
 CO 
 
 O 
 
 CO 05 tx tx. 
 
 CO 
 
 Of 
 
 0 
 
 0 
 
 CO 
 
 
 
 
 O 
 
 
 
 rH 
 
 
 05 
 
 rH 
 
 rH 
 
 05 
 
 rH 
 
 rH 
 
 
 rH 
 
 rH 
 
 05 
 
 05 
 
 05 rH 
 
 05 05 
 
 0 
 
 O 
 
 05 
 
 00 
 
 00 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 rH 
 
 rH 
 
 
 
 
 
 
 
 
 10 
 
 05 
 
 05 
 
 CO 
 
 05 
 
 rH 
 
 50 
 
 05 
 
 00 
 
 0 
 
 CO 
 
 05 
 
 0 
 
 no 
 
 00 
 
 Xt 00 
 
 05 Of 
 
 05 
 
 00 
 
 Of 
 
 CO 
 
 0 
 
 
 
 
 05 
 
 rH 
 
 rH 
 
 rH 
 
 no 
 
 CO 
 
 CO 
 
 Xt 
 
 x*l 
 
 xt 
 
 0 
 
 CO 
 
 no 
 
 Xt 
 
 0 
 
 OO 
 
 no tx co 00 
 
 CO 
 
 xt 
 
 05 
 
 no 
 
 Of 
 
 • 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 rH 
 
 
 
 
 rH 
 
 Of 
 
 
 05 
 
 05 
 
 a 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 w-i 
 
 
 
 
 CO 
 
 no 
 
 00 
 
 co 
 
 tx 
 
 fx 
 
 O 
 
 05 
 
 05 
 
 00 
 
 rH 
 
 00 
 
 05 
 
 rH 
 
 00 
 
 fx 05 
 
 no 05 
 
 tx 
 
 05 
 
 00 
 
 no tx 
 
 
 
 
 O 
 
 
 
 
 05 
 
 rH 
 
 05 
 
 05 
 
 rH 
 
 05 
 
 05 
 
 CO 
 
 05 
 
 rH 
 
 no 
 
 Xtl 
 
 05 CO 
 
 CO xt 
 
 00 
 
 Of 
 
 xt 
 
 no 
 
 CO 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 rH 
 
 
 r-H 
 
 rH 
 
 
 
 
 
 CO 
 
 05 
 
 05 
 
 00 
 
 CO 
 
 00 
 
 rH 
 
 05 
 
 no 
 
 CO 
 
 tx 
 
 O- 
 
 CO 
 
 CO 
 
 CO 
 
 00 no 
 
 H CO 
 
 CO 
 
 CO 
 
 no 
 
 50 
 
 Of 
 
 
 
 
 PS 
 
 
 CO 
 
 05 
 
 Xt 
 
 05 
 
 CO 
 
 05 
 
 CO 
 
 X* 
 
 no 
 
 no 
 
 OO 
 
 no 
 
 rH 
 
 no 
 
 0 no 
 
 no 0 
 
 00 
 
 00 
 
 00 
 
 rH 
 
 0 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 rH 
 
 
 rH rH 
 
 rH rH 
 
 rH 
 
 Of 
 
 
 co 
 
 C^5 
 
 a 
 
 
 
 
 rH 
 
 co 
 
 05 
 
 0 
 
 rH 
 
 05 
 
 05 fx 
 
 0 
 
 no 
 
 co 
 
 O 
 
 CO 
 
 CO 
 
 no 
 
 05 50 
 
 Xt 1—1 CO Xt 
 
 eo 
 
 tx 
 
 Of 
 
 
 
 
 O 
 
 
 rH 
 
 rH 
 
 05 
 
 rH 
 
 05 
 
 
 rH 
 
 05 
 
 05 
 
 05 
 
 xt 
 
 05 
 
 no 
 
 05 
 
 no tx tx 10 C5 
 
 xt 
 
 Xt 
 
 00 
 
 Of 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 rH 
 
 
 rH 
 
 rH 
 
 
 
 
 
 N 
 
 xt 
 
 rH 
 
 CO 
 
 xt 
 
 00 
 
 00 
 
 CO 
 
 O- 
 
 CO N 05 
 
 CO 
 
 0 
 
 xt 
 
 rH O 
 
 no 05 
 
 xt 
 
 0 
 
 CO 
 
 co 
 
 tx 
 
 • 
 
 
 
 05 
 
 rH 
 
 no 
 
 05 
 
 no 
 
 CO 
 
 CO 
 
 no 
 
 CO 
 
 no 
 
 xtf 
 
 00 
 
 05 
 
 rH 
 
 CO 
 
 O 
 
 CO 0 
 
 CO 0 
 
 Xt 
 
 xt 
 
 05 
 
 rH 
 
 CO 
 
 pC 
 
 0 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 rH 
 
 rH 
 
 rH 
 
 1 —1 05 
 
 05 Of 
 
 Of 
 
 CO 
 
 
 co 
 
 05 
 
 Ih 
 
 
 
 
 tx 
 
 co 
 
 05 
 
 Xt 
 
 no 
 
 0 
 
 CO 
 
 0 
 
 CO 
 
 O 
 
 HNtO 
 
 CO 
 
 HlftO 
 
 Xt tx CO 
 
 O 
 
 05 
 
 Of 
 
 00 
 
 s 
 
 
 
 O 
 
 
 <05 
 
 
 05 
 
 rH 
 
 CO 
 
 05 
 
 co 
 
 05 
 
 05 
 
 xt 
 
 xt 
 
 no 
 
 CO 
 
 no 
 
 CO 0 
 
 CO 0 
 
 Of 
 
 00 
 
 xt 
 
 05 
 
 xt 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 rH 
 
 rH rH 
 
 rH 
 
 rH 
 
 
 rH 
 
 rH 
 
 
 
 
 
 CO 
 
 tx 
 
 Xt 
 
 05 
 
 00 
 
 0 
 
 •x* 
 
 05 
 
 O 
 
 00 
 
 05 
 
 CO 
 
 eo 
 
 N 
 
 no 
 
 O 05 
 
 CO xt 
 
 CO 
 
 rH 
 
 no 
 
 rH 
 
 rH 
 
 
 
 
 PS 
 
 rH 
 
 co 
 
 •<*1 
 
 tx 
 
 xt tx 
 
 X* 
 
 rH 
 
 CO 
 
 xt 
 
 05 
 
 rH 
 
 co 
 
 0 
 
 co 
 
 50 r-H 
 
 05 CO 
 
 05 
 
 Of 
 
 rH 
 
 CO 
 
 rH 
 
 .£5 
 
 
 
 
 
 
 
 
 
 
 
 rH 
 
 
 
 
 rH 
 
 05 
 
 rH 
 
 rH 
 
 1—1 05 
 
 co of 
 
 CO 
 
 CO 
 
 05 
 
 Of 
 
 co 
 
 <D 
 
 
 
 
 no 
 
 xt 
 
 
 00 
 
 05 
 
 00 
 
 00 co 
 
 no 
 
 O 
 
 05 
 
 0 
 
 rH 
 
 tx 
 
 ON® 
 
 05 00 
 
 Of 
 
 rH 
 
 05 
 
 00 
 
 no 
 
 
 
 
 O 
 
 
 rH 
 
 rH 
 
 05 
 
 rH 
 
 05 
 
 rH 
 
 X* 
 
 05 
 
 05 
 
 CO 
 
 no 
 
 0 
 
 x* 
 
 CO 
 
 CO 05 
 
 Xt O 
 
 no 
 
 no 
 
 O 
 
 05 
 
 tx 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 rH 
 
 
 
 
 rH rH 
 
 rH 
 
 rH 
 
 rH 
 
 rH 
 
 rH 
 
 
 
 
 
 xt 
 
 co 
 
 rH 
 
 rH 
 
 00 
 
 00 05 
 
 no 
 
 00 
 
 00 
 
 rH 
 
 tx tx <o 
 
 Xt 
 
 xt r-l CO tx 
 
 rH 
 
 fx CO 
 
 05 
 
 tx 
 
 
 
 
 05 
 
 (M 
 
 Xt 
 
 co 
 
 05 
 
 
 CO 
 
 rH 
 
 xt< CO 
 
 no 
 
 05 
 
 co 
 
 co 
 
 00 
 
 CO 
 
 50 Xt 
 
 tx 0 
 
 CO 
 
 fx 
 
 co 
 
 rH 
 
 0 
 
 a 
 
 
 
 
 
 
 
 
 
 
 rH 
 
 rH 
 
 rH 
 
 
 
 rH 
 
 05 
 
 
 H 05 05 
 
 05 CO 
 
 CO 
 
 rH 
 
 xt 
 
 rH 
 
 no 
 
 73 
 
 
 
 
 O 
 
 00 
 
 CO 
 
 05 
 
 xt 
 
 05 
 
 OONNW 
 
 no 
 
 X* 
 
 05 
 
 CO CO H 
 
 00 tx CO 
 
 05 
 
 co 
 
 CO co 
 
 
 
 
 O 
 
 rH 
 
 rH 
 
 rH 
 
 CO 
 
 CO 
 
 CO 
 
 no co tx 05 x* 
 
 co 
 
 rH 
 
 xt 
 
 CO 
 
 05 05 
 
 CO no 
 
 GO 
 
 05 
 
 xt 
 
 tx 
 
 rH 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 rH 
 
 
 
 rH rH 
 
 rH rH 
 
 rH 
 
 
 05 
 
 
 co 
 
 
 Year. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 r- 
 
 00 
 
 05 
 
 O 
 
 rH 
 
 05 
 
 co 
 
 xt 
 
 no 
 
 co 
 
 N 
 
 00 
 
 05 
 
 O 
 
 rH 
 
 05 CO 
 
 xt no co tx 
 
 00 
 
 05 
 
 0 
 
 
 
 
 
 05 
 
 05 
 
 05 
 
 O 
 
 0 
 
 O 
 
 0 
 
 O 
 
 0 
 
 0 
 
 O 
 
 0 
 
 O 
 
 rH 
 
 rH 
 
 rH rH 
 
 rH rH 
 
 rH 
 
 rH 
 
 rH 
 
 rH 
 
 05 
 
 
 
 
 
 00 
 
 00 
 
 00 
 
 05 
 
 05 
 
 05 
 
 C5 
 
 C5 
 
 05 
 
 05 
 
 C5 
 
 05 
 
 05 
 
 05 
 
 05 
 
 05 05 
 
 05 05 
 
 05 
 
 05 
 
 05 
 
 05 
 
 05 
 
 
 
 
 
 rH 
 
 rH 
 
 rH 
 
 rH 
 
 rH 
 
 rH 
 
 rH 
 
 rH 
 
 rH 
 
 rH 
 
 rH 
 
 rH 
 
 rH 
 
 rH 
 
 rH 
 
 rH rH 
 
 rH rH 
 
 rH 
 
 rH 
 
 rH 
 
 rH 
 
 rH 
 
298 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 was no significant difference in morbidity among whites and negroes, and in 
 respect of the two sexes the difference was not great. However, the highest 
 rates occurred in white males and the lowest in white females. From 1 to 4 
 
 Table 42. —Number of cases and rate of morbidity, per 100,000 living inhabitants in 
 1920, for chicken-pox and mumps, according to age, color, and sex, for 1921. 
 
 C — cases. R = rate. 
 
 Chicken-pox. 
 
 Age-groups. 
 
 Total. 
 
 
 
 White. 
 
 
 
 
 
 Colored. 
 
 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 
 C 
 
 R 
 
 C 
 
 R 
 
 C 
 
 R 
 
 C 
 
 R 
 
 C 
 
 R 
 
 C 
 
 R 
 
 C 
 
 R 
 
 Under 1 year 
 
 98 
 
 660 
 
 85 
 
 660 
 
 51 
 
 773 
 
 34 
 
 541 
 
 13 
 
 661 
 
 6 
 
 627 
 
 7 
 
 692 
 
 1 to 4 years 
 
 484 
 
 888 
 
 426 
 
 886 
 
 220 
 
 911 
 
 206 
 
 860 
 
 58 
 
 905 
 
 20 
 
 642 
 
 38 
 
 1154 
 
 0 to 4 years 
 
 582 
 
 839 
 
 511 
 
 838 
 
 271 
 
 881 
 
 240 
 
 554 
 
 71 
 
 848 
 
 26 
 
 639 
 
 45 
 
 1045 
 
 5 to 9 years 
 
 1118 
 
 1734 
 
 1053 
 
 1866 
 
 540 
 
 1889 
 
 513 
 
 1843 
 
 65 
 
 806 
 
 42 
 
 1088 
 
 23 
 
 547 
 
 0 to 9 years 
 
 1700 
 
 1270 
 
 1564 
 
 1332 
 
 811 
 
 1367 
 
 753 
 
 1297 
 
 136 
 
 827 
 
 68 
 
 857 
 
 68 
 
 799 
 
 10 to 19 years 
 
 186 
 
 150 
 
 165 
 
 153 
 
 75 
 
 142 
 
 90 
 
 164 
 
 21 
 
 132 
 
 9 
 
 127 
 
 12 
 
 135 
 
 20 to 29 years 
 
 30 
 
 21 
 
 19 
 
 16 
 
 13 
 
 22 
 
 6 
 
 10 
 
 11 
 
 43 
 
 6 
 
 49 
 
 5 
 
 37 
 
 30 to 39 years 
 
 16 
 
 13 
 
 11 
 
 11 
 
 6 
 
 12 
 
 5 
 
 10 
 
 5 
 
 23 
 
 5 
 
 45 
 
 • • • 
 
 « • • • 
 
 40 to 49 years 
 
 5 
 
 5 
 
 3 
 
 4 
 
 2 
 
 5 
 
 1 
 
 3 
 
 2 
 
 13 
 
 1 
 
 12 
 
 1 
 
 14 
 
 50 to 59 years 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 60 to 69 years 
 
 1 
 
 3 
 
 1 
 
 3 
 
 1 
 
 7 
 
 
 
 
 
 
 
 
 
 70 to 79 years 
 80 years and 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 over . 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Total .. 
 
 1938 
 
 264 
 
 1763 
 
 282 
 
 908 
 
 294 
 
 855 
 
 270 
 
 175 
 
 161 
 
 89 
 
 167 
 
 86 
 
 155 
 
 Age-groups. 
 
 Mumps. 
 
 Total. 
 
 White. 
 
 Colored. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 C 
 
 R 
 
 C 
 
 R 
 
 C 
 
 R 
 
 C 
 
 R 
 
 C 
 
 R 
 
 C 
 
 R 
 
 C 
 
 R 
 
 Under 1 year. 
 
 2 
 
 13 
 
 2 
 
 16 
 
 2 
 
 30 
 
 
 
 
 
 
 
 
 
 1 to 4 years. 
 
 97 
 
 178 
 
 79 
 
 164 
 
 49 
 
 203 
 
 30 
 
 125 
 
 18 
 
 281 
 
 11 
 
 353 
 
 7 
 
 213 
 
 0 to 4 years. 
 
 99 
 
 143 
 
 81 
 
 133 
 
 51 
 
 166 
 
 30 
 
 69 
 
 18 
 
 215 
 
 11 
 
 270 
 
 7 
 
 163 
 
 5 to 9 years. 
 
 476 
 
 738 
 
 438 
 
 776 
 
 262 
 
 917 
 
 176 
 
 632 
 
 38 
 
 471 
 
 20 
 
 518 
 
 18 
 
 428 
 
 0 to 9 years. 
 
 575 
 
 430 
 
 519 
 
 442 
 
 313 
 
 528 
 
 206 
 
 355 
 
 56 
 
 341 
 
 31 
 
 391 
 
 25 
 
 294 
 
 10 to 19 years. 
 
 175 
 
 141 
 
 128 
 
 119 
 
 69 
 
 131 
 
 59 
 
 107 
 
 47 
 
 295 
 
 22 
 
 311 
 
 25 
 
 281 
 
 20 to 29 years. 
 
 38 
 
 26 
 
 29 
 
 24 
 
 16 
 
 27 
 
 13 
 
 22 
 
 9 
 
 35 
 
 5 
 
 41 
 
 4 
 
 29 
 
 30 to 39 years. 
 
 19 
 
 16 
 
 17 
 
 17 
 
 10 
 
 20 
 
 7 
 
 14 
 
 2 
 
 9 
 
 • • • 
 
 • • • 
 
 2 
 
 19 
 
 40 to 49 years. 
 
 1 
 
 1 
 
 1 
 
 1 
 
 1 
 
 3 
 
 
 
 
 
 
 
 
 
 50 to 59 years. 
 
 2 
 
 3 
 
 2 
 
 4 
 
 • • • 
 
 • • • 
 
 2 
 
 7 
 
 
 
 
 
 
 
 60 to 69 years. 
 
 1 
 
 3 
 
 1 
 
 3 
 
 • • • 
 
 • • • 
 
 1 
 
 6 
 
 
 
 
 
 
 
 70 to 79 years. 
 
 1 
 
 7 
 
 1 
 
 8 
 
 • • • 
 
 • • • 
 
 1 
 
 13 
 
 
 
 
 
 
 
 80 years and over.... 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Total . 
 
 812 
 
 111 
 
 698 
 
 112 
 
 409 
 
 133 
 
 289 
 
 91 
 
 114 
 
 105 
 
 58 
 
 109 
 
 56 
 
 101 
 
 years, with rates somewhat higher for negroes than for whites, the incidence 
 was again higher in whites among males and in negroes among females. The 
 consequence is that for the age period 0 to 4 years morbidity was practically 
 
FEBRILE DISEASES 
 
 299 
 
 the same for whites and negroes, among whites considerably higher for males 
 than for females, and among negroes for females than for males. In the age- 
 group 5 to 9 years, morbidity among whites was more than double that among 
 negroes, on about the same level for the tw r o sexes in whites, but twice as great 
 for males as for females in negroes. As a net result in the first decade of life, 
 in which the overwhelming majority of the cases occurred, the rate of incidence 
 was greater in whites than in negroes by about one-fourth and somewhat greater 
 in males than in females of both races. 
 
 SCARLET FEVER. 
 
 The annals of Baltimore do not mention the occurrence of scarlet fever in 
 the eighteenth century, and, if it appeared at all, it was probably in a form so 
 
 Graph 13 (from table 34). Annual crude mortality-rates from scarlet fever 
 
 and measles, from 1812 to 1920, inclusive. 
 
 mild that few or no deaths were attributable to it. However, as in those times, 
 and indeed until well after the middle of the nineteenth century, it was included 
 among that group of diseases generally regarded as necessary afflictions of the 
 human race, inevitable, uncontrollable, and, therefore, except when present in 
 the form of severe epidemic visitation, it would not, unless by chance, have 
 found space in local chronicles. That the disease was imported repeatedly from 
 Europe and passed at quarantine there is no doubt. As late as 1895, cases were 
 often sent in large numbers from immigrant ships to the University of Mary¬ 
 land and other hospitals, where provisions for isolation were primitive in the 
 extreme. It is probable that, between 1830 and 1900, due to classification under 
 dropsy, nephritis, middle-ear disease, meningitis, and even diphtheria, and 
 the rubrics for other complications, the number of deaths from scarlet fever was 
 actually larger than officially recorded. The course of the curve for the annual 
 mortality for the whole period (table 34, graph 13) is marked by wide fluctua- 
 20 
 
300 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 tions, which are in general of two general types. Fluctuations of the first type 
 depend upon differences in the general level of the rates over comparatively 
 long series of years and represent true waves of high or low mortality. Three 
 such waves stand out until distinctness. 
 
 The first wave, characterized by very low mortality, covers approximately 
 the second and third decades of the nineteenth century, when, in fatal form 
 at least, scarlet fever was rare in Baltimore. Between 1811 and 1829 there were 
 but 13 recorded deaths. The first was in 1814, and then after an interval of 
 5 years there were 4 in 1820 and 3 in 1821. With 1 death in 1823, and 3 in 
 1825, 4 years elapsed before the single fatality in 1829. As judged by recorded 
 fatalities during this period, scarlet fever occurred only sporadically; if 
 endemically established the disease was extremely mild. Quite different was 
 its course after 1829. Since this date, in every year scarlet fever has been 
 credited with deaths, and probably at no time has the city been entirely free 
 from cases. 
 
 After the sudden outbreak in 1830, with a death rate of 172, the disease 
 entered on a long wave of high mortality, which, though broken here and there 
 by recessions, lasted until 1885. In many of these 55 years the disease was a 
 veritable scourge. Years of exceptionally high fatality were 1844, 1845, 1853, 
 1858, 1862, and 1871, when the rates were 270, 204, 263, 203, 263, 255, and 224, 
 respectively. As late as 1875 and 1876 the rates were as high as in 1830 and 
 1831. After 1880 the rate did not surpass 100. 
 
 The third wave, which embraces the period since 1885, is characterized by 
 lower and gradually declining rates. During this time the highest rates attained 
 were 57 in 1892, 29 in 1891, and 27 in 1904. Rates as low as 2 were recorded 
 in 1901, 1917, and 1920, and in 1918 the rate was 1. Since 1905, scarlet fever 
 in Baltimore has almost lost its lethal force, which now exhibits a strong 
 tendency to decline to the level obtaining previous to 1830. 
 
 The second type of fluctuation in the annual rates is dependent upon a quite 
 different characteristic, namely, the frequent occurrence of minor epidemic 
 waves extending over 2 or 3 years and followed by from one to several years of 
 remission, or, even in some periods, of complete intermission. These minor 
 waves recur constantly, though not always at equal intervals, whether the 
 general level of mortality be low or high, and evidently reflect inherent charac¬ 
 ters of the disease. 
 
 A much clearer picture of the course of scarlet fever is given by the curve of 
 the mortality-rates as averaged for 5-year periods (table 43, graph 14). With 
 rates of 1 for the periods ending in 1815 and 1820 and of 2 for that ending 
 in 1825, the rates for the period ending in 1830 jumped to 35, owing to the 
 sudden outbreak of the disease in this year. From 1835, the curve of the aver¬ 
 aged rates, except for slight recessions in 1836-1840 and 1851-1855, rose 
 steadily to 151 in 1856-1860. This represents the peak of the mortality of 
 this disease. Falling during the next 10 years the averaged rate was 62 in 
 1866-1870. Reacting from this, the rates moved upward during 10 years to 
 119 in 1876-1880. This was followed by a fall in the rates to 50 in 1881-1885 
 and to 11 in 1886-1890. From this low level there was a reaction to 25 in 1891- 
 1895, but by 1896-1900 the rate had fallen to 7. For the succeeding 5 years 
 this rate rose to 12, only to fall to 7 in 1906-1910, 6 in 1911-1915, and 3 in 
 1916-1920. 
 
FEBRILE DISEASES 
 
 301 
 
 Table 43.— Average rate of death by 5- and 10-ycar -periods from total acute exanthema¬ 
 tous diseases, from 1812 to 1020, inclusive. 
 
 Periods. 
 
 Small-pox. 
 
 Varicella. 
 
 Scarlet 
 
 fever. 
 
 Measles. 
 
 Influenza. 
 
 Total acute 
 exan¬ 
 thematous 
 diseases. 
 
 By 5-vear 
 periods. 
 
 By 10-year 
 periods. 
 
 By 5-year 
 
 periods. 
 
 By 10-year 
 
 periods. 
 
 By 5-year 
 
 periods. 
 
 By 10-year 
 
 periods. 
 
 By 5-year 
 
 periods. 
 
 By 10-vear 
 
 periods. 
 
 By 5-year 
 
 periods. 
 
 Bv 10-year 
 
 periods. 
 
 By 5-year 
 
 periods. 
 
 By 10-year 
 
 periods. 
 
 1812-15 . 
 
 46 
 
 • • • 
 
 
 
 1 
 
 
 24 
 
 • • • 
 
 13 
 
 • • • 
 
 83 
 
 
 1816-20 . 
 
 2 
 
 21 
 
 
 
 1 
 
 1 
 
 45 
 
 35 
 
 1 
 
 6 
 
 48 
 
 64 
 
 1821-25 . 
 
 48 
 
 • • • 
 
 
 
 2 
 
 • • • 
 
 62 
 
 • • • 
 
 • • • 
 
 • • • 
 
 132 
 
 • • • 
 
 1826-30 . 
 
 4 
 
 26 
 
 
 
 35 
 
 18 
 
 14 
 
 38 
 
 • • • 
 
 • • • 
 
 53 
 
 83 
 
 1831-35 . 
 
 44 
 
 • • • 
 
 
 
 101 
 
 • • • 
 
 25 
 
 • • • 
 
 32 
 
 • • • 
 
 202 
 
 • • • 
 
 1836-40 . 
 
 25 
 
 35 
 
 2 
 
 1 
 
 86 
 
 93 
 
 42 
 
 33 
 
 • • • 
 
 16 
 
 154 
 
 178 
 
 1841-45 . 
 
 16 
 
 • • • 
 
 • • • 
 
 
 119 
 
 • • • 
 
 21 
 
 • • • 
 
 1 
 
 • • • 
 
 157 
 
 • • • 
 
 1846-50 . 
 
 38 
 
 27 
 
 1 
 
 
 140 
 
 129 
 
 31 
 
 26 
 
 1 
 
 1 
 
 210 
 
 183 
 
 1851-55 . 
 
 29 
 
 • • • 
 
 1 
 
 
 135 
 
 • • • 
 
 53 
 
 • • • 
 
 
 • • • 
 
 218 
 
 • • • 
 
 1856-60 . 
 
 41 
 
 35 
 
 1 
 
 1 
 
 151 
 
 143 
 
 41 
 
 47 
 
 
 • • • 
 
 233 
 
 225 
 
 1861-65 . 
 
 63 
 
 • • • 
 
 1 
 
 
 122 
 
 • • • 
 
 29 
 
 • • • 
 
 
 • • • 
 
 215 
 
 • • • 
 
 1866-70 . 
 
 1 
 
 32 
 
 • • • 
 
 1 
 
 62 
 
 92 
 
 44 
 
 36 
 
 
 • • • 
 
 107 
 
 161 
 
 1871-75 . 
 
 105 
 
 • • • 
 
 1 
 
 
 112 
 
 • • • 
 
 30 
 
 • • • 
 
 
 • • • 
 
 248 
 
 • 90 
 
 1876-80 . 
 
 • • • 
 
 53 
 
 
 
 119 
 
 116 
 
 15 
 
 22 
 
 
 • • • 
 
 133 
 
 191 
 
 1881-85 . 
 
 67 
 
 • • • 
 
 
 
 50 
 
 • • • 
 
 29 
 
 • • • 
 
 
 • • • 
 
 147 
 
 ... 
 
 1886-90 . 
 
 
 34 
 
 
 
 11 
 
 31 
 
 35 
 
 32 
 
 1 
 
 • • • 
 
 47 
 
 97 
 
 1891-95 . 
 
 
 • • • 
 
 
 
 25 
 
 • • • 
 
 11 
 
 • • • 
 
 36 
 
 • • • 
 
 72 
 
 • • • 
 
 1896-1900 . 
 
 
 • • • 
 
 
 
 7 
 
 16 
 
 5 
 
 8 
 
 21 
 
 29 
 
 33 
 
 53 
 
 1901-05 . 
 
 
 • • • 
 
 
 
 12 
 
 • • • 
 
 7 
 
 • • • 
 
 17 
 
 • • • 
 
 37 
 
 • • • 
 
 1906-10 . 
 
 
 • • • 
 
 
 
 7 
 
 9 
 
 6 
 
 7 
 
 17 
 
 17 
 
 31 
 
 34 
 
 1911-15 . 
 
 
 • • • 
 
 
 
 6 
 
 • • • 
 
 8 
 
 • • • 
 
 13 
 
 • • • 
 
 27 
 
 • • • 
 
 1916-20 . 
 
 
 • • • 
 
 
 
 3 
 
 4 
 
 7 
 
 7 
 
 84 
 
 48 
 
 94 
 
 60 
 
 Graph 14 (from table 43). Crude mortality-rates from scarlet fever and 
 measles, averaged by 5-year periods, from 1812 to 1920, inclusive 
 
302 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 Owing to the very great variation in the annual mortality rates, the rates 
 as averaged for 10-years periods (table 43, graph 15) give perhaps an even 
 more correct picture of the course of the lethal force of this disease. As a 
 result of the greater smoothing, the progress of the curve of the rates is 
 unbrokenly upward to 1851-1860, with a rate of 143, and from this point, but 
 for a slight reaction in 1871-1880, the course of the curve is continuously 
 downward. The rates for the last four decennia were 31, 16, 9, and 4. 
 
 From this analysis it is clear that the lethal force of scarlet fever, negligible 
 before 1830, gained continuously in vigor for three decades and reached its 
 zenith in that ending in 1860, and since this date it has gradually and almost 
 
 Graph 15 (from table 43). Crude mortality-rates from scarlet fever and 
 measles, averaged by 10-year periods, from 1812 to 1920, inclusive. 
 
 uninterruptedly lost in strength, so that 40 years later (1900) it had returned 
 to the level of 1830. By 1920 the force of mortality had fallen almost to the 
 level of 1820. In this century scarlet fever, considered as a cause of mortality, 
 had risen gradually from a position of no importance to become for many years 
 a scourge and had fallen as gradually back to its primary position. 
 
 As at least 90 per cent of all deaths from scarlet fever occur in individuals 
 under 10 years of age and 70 per cent in those under 5 years, any considerable 
 changes in the proportional relations of these age-groups to the whole popu¬ 
 lation must have exerted an important influence upon the course of its mor¬ 
 tality. Between 1850 and 1920, the proportions in the population of individuals 
 in age-group 0 to 4 years declined by 34 per cent, in age-group 5 to 9 years 
 by 26 per cent, and in age group 0 to 9 years by 31 per cent, and it may be 
 held that the decline in the scarlet-fever death-rate during this period was 
 
FEBRILE DISEASES 
 
 303 
 
 influenced in something like these ratios solely by shrinkage in these propor¬ 
 tions in the relative numbers of individuals of susceptible age. In table 44 are 
 given the rates for scarlet fever for the census years from 1830 to 1920, inclu¬ 
 sive, calculated on the basis of the populations under 10 years of age. These 
 rates, within somewhat broad limits, specific for age for these particular years, 
 demark the course of this disease with much greater precision than do the crude 
 
 Table 44.— Number of deaths and rate of death, per 100,000 living inhabitants under 
 10 years of age, from scarlet fever and measles, for the decennia 1830 to 1920, 
 inclusive. 
 
 D = death. R = rate. 
 
 Year. 
 
 Scarlet 
 
 fever. 
 
 Measles. 
 
 Year. 
 
 Scarlet 
 
 fever. 
 
 Measles. 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 1830. 
 
 103 
 
 495 
 
 25 
 
 120 
 
 1880. 
 
 327 
 
 440 
 
 43 
 
 58 
 
 1840. 
 
 85 
 
 318 
 
 32 
 
 120 
 
 1890. 
 
 80 
 
 87 
 
 92 
 
 101 
 
 1850. 
 
 204 
 
 457 
 
 20 
 
 45 
 
 1900. 
 
 18 
 
 18 
 
 11 
 
 11 
 
 1860. 
 
 223 
 
 397 
 
 59 
 
 105 
 
 1910. 
 
 39 
 
 38 
 
 50 
 
 49 
 
 1870. 
 
 350 
 
 537 
 
 124 
 
 190 
 
 1920. 
 
 14 
 
 10 
 
 18 
 
 13 
 
 * The number of deaths for each decenniom is a 3-year average of that obtaining 
 in the decennial year and in those years immediately preceding and following, except in 
 1920 when the average is for 1919 and 1920 only. 
 
 rates already considered. It is obvious that the picture is somewhat distorted, 
 for had the calculations been extended to include every year, rates much 
 higher and much lower than those obtained would have been found. 
 
 Frick’s analysis of the deaths from scarlet fever in Baltimore in 1850 showed 
 rates per 10,000 inhabitants of 13.8 for whites and 10.8 for blacks; the lesser 
 mortality among the blacks he thought was probably due to the greater diffi¬ 
 culty in diagnosis of the disease in this race. Classified according to sex, 49 
 per cent of the deaths were in males and 51 per cent were in females. The 
 proportion of the 225 deaths he ascribed to the different ages is shown in 
 table 45. 
 
 Table 45. 
 
 p. c. 
 
 Under 1 year. 10.9 
 
 Between 1 and 2 years. 25.1 
 
 Between 2 and 3 years. 20.0 
 
 Between 3 and 4 years. 10.9 
 
 Between 4 and 5 years. 9.1 
 
 Between 5 and 10 years. 20.0 
 
 Between 10 and 20 years. 9.7 
 
 Over 20 years. 0.3 
 
 The death-rates specific for age are given in table 36 (p. 284). 
 
 In one of the few allusions in the annual reports to the specific qualities of 
 scarlet fever, the commissioner of health, in 1870, in the midst of the period 
 of its greatest fatality, remarked that it attacked persons of all ages, but con¬ 
 fined its ravages principally to children between 3 and 9 years, and that few 
 diseases were so prevalent among children and none more fatal. 
 
304 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 Of the 488 deaths recorded from scarlet fever during the 15-year period 
 1905-1919, 457 were in whites, with 227 in males and 230 in females, and 31 
 were in negroes, with 15 in males and 16 in females (table 46). While there 
 are no significant differences in the mortality between males and females 
 
 Table 46. —Number oj deaths and rate oj death, per 100,000 living inhabitants, from 
 scarlet fever and measles, according to color and sex, from 1905 to 1919, inclusive. 
 
 SCARLET FEVER. 
 
 D = death. R = rate. 
 
 Year. 
 
 Total. 
 
 White. 
 
 Colored. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 1905 . 
 
 32 
 
 6 
 
 29 
 
 6 
 
 18 
 
 8 
 
 11 
 
 5 
 
 3 
 
 4 
 
 2 
 
 5 
 
 1 
 
 2 
 
 1906 . 
 
 43 
 
 8 
 
 41 
 
 9 
 
 13 
 
 6 
 
 28 
 
 12 
 
 2 
 
 2 
 
 1 
 
 3 
 
 1 
 
 2 
 
 1907 . 
 
 14 
 
 3 
 
 14 
 
 3 
 
 7 
 
 3 
 
 7 
 
 3 
 
 
 
 
 
 
 
 1908 . 
 
 70 
 
 13 
 
 66 
 
 14 
 
 29 
 
 13 
 
 37 
 
 15 
 
 4 
 
 5 
 
 2 
 
 5 
 
 2 
 
 4 
 
 1909 . 
 
 22 
 
 4 
 
 22 
 
 5 
 
 13 
 
 6 
 
 9 
 
 4 
 
 
 
 
 
 
 
 1910 . 
 
 49 
 
 9 
 
 47 
 
 10 
 
 24 
 
 10 
 
 23 
 
 9 
 
 2 
 
 2 
 
 1 
 
 2 
 
 1 
 
 2 
 
 1911 . 
 
 44 
 
 8 
 
 41 
 
 8 
 
 21 
 
 9 
 
 20 
 
 8 
 
 3 
 
 3 
 
 1 
 
 2 
 
 2 
 
 4 
 
 1912 . 
 
 23 
 
 4 
 
 22 
 
 4 
 
 9 
 
 4 
 
 13 
 
 5 
 
 1 
 
 1 
 
 • • • 
 
 • • • 
 
 1 
 
 2 
 
 1913 . 
 
 45 
 
 8 
 
 42 
 
 8 
 
 24 
 
 10 
 
 18 
 
 7 
 
 3 
 
 3 
 
 1 
 
 2 
 
 2 
 
 4 
 
 1914 . 
 
 35 
 
 6 
 
 28 
 
 6 
 
 14 
 
 6 
 
 14 
 
 6 
 
 7 
 
 7 
 
 3 
 
 7 
 
 4 
 
 8 
 
 1915 . 
 
 32 
 
 5 
 
 29 
 
 6 
 
 18 
 
 7 
 
 11 
 
 4 
 
 3 
 
 3 
 
 1 
 
 2 
 
 2 
 
 4 
 
 1916 . 
 
 30 
 
 5 
 
 30 
 
 6 
 
 13 
 
 5 
 
 17 
 
 7 
 
 
 
 
 
 
 
 1917 . 
 
 11 
 
 2 
 
 11 
 
 2 
 
 6 
 
 2 
 
 5 
 
 2 
 
 
 
 
 
 
 
 1918 . 
 
 8 
 
 1 
 
 C 
 
 1 
 
 4 
 
 2 
 
 2 
 
 1 
 
 2 
 
 2 
 
 2 
 
 4 
 
 • • • 
 
 • • • 
 
 1919 . 
 
 30 
 
 4 
 
 29 
 
 5 
 
 14 
 
 5 
 
 15 
 
 5 
 
 1 
 
 1 
 
 1 
 
 2 
 
 • • • 
 
 • • • 
 
 MEASLES. 
 
 1905 . 
 
 84 
 
 16 
 
 65 
 
 14 
 
 33 
 
 7 
 
 32 
 
 14 
 
 19 
 
 23 
 
 8 
 
 21 
 
 11 
 
 24 
 
 1906 . 
 
 10 
 
 2 
 
 8 
 
 2 
 
 3 
 
 1 
 
 5 
 
 2 
 
 2 
 
 2 
 
 1 
 
 3 
 
 1 
 
 O 
 
 1907 . 
 
 67 
 
 12 
 
 49 
 
 10 
 
 23 
 
 10 
 
 26 
 
 11 
 
 18 
 
 21 
 
 5 
 
 13 
 
 13 
 
 27 
 
 1908 . 
 
 17 
 
 3 
 
 15 
 
 3 
 
 8 
 
 3 
 
 7 
 
 3 
 
 2 
 
 2 
 
 2 
 
 5 
 
 • • • 
 
 • • • 
 
 1909 . 
 
 51 
 
 9 
 
 37 
 
 7 
 
 23 
 
 10 
 
 14 
 
 6 
 
 14 
 
 16 
 
 8 
 
 20 
 
 6 
 
 12 
 
 1910 . 
 
 17 
 
 3 
 
 16 
 
 3 
 
 11 
 
 5 
 
 5 
 
 2 
 
 1 
 
 1 
 
 • • • 
 
 • • • 
 
 1 
 
 2 
 
 1911 . 
 
 73 
 
 13 
 
 60 
 
 12 
 
 32 
 
 13 
 
 28 
 
 11 
 
 13 
 
 14 
 
 8 
 
 19 
 
 5 
 
 10 
 
 1912 . 
 
 5 
 
 1 
 
 5 
 
 1 
 
 2 
 
 1 
 
 3 
 
 1 
 
 
 
 
 
 
 
 1913 . 
 
 115 
 
 19 
 
 86 
 
 17 
 
 50 
 
 20 
 
 36 
 
 14 
 
 29 
 
 31 
 
 20 
 
 47 
 
 9 
 
 18 
 
 1914 . 
 
 5 
 
 1 
 
 5 
 
 1 
 
 1 
 
 
 4 
 
 2 
 
 
 
 
 
 
 
 1915 . 
 
 17 
 
 3 
 
 13 
 
 3 
 
 5 
 
 2 
 
 8 
 
 3 
 
 4 
 
 4 
 
 2 
 
 5 
 
 2 
 
 4 
 
 1916 . 
 
 34 
 
 6 
 
 29 
 
 6 
 
 17 
 
 7 
 
 12 
 
 5 
 
 5 
 
 5 
 
 3 
 
 7 
 
 2 
 
 4 
 
 1917 . 
 
 51 
 
 8 
 
 40 
 
 8 
 
 20 
 
 8 
 
 20 
 
 8 
 
 11 
 
 11 
 
 6 
 
 13 
 
 5 
 
 9 
 
 1918 . 
 
 75 
 
 12 
 
 62 
 
 12 
 
 29 
 
 11 
 
 33 
 
 13 
 
 13 
 
 13 
 
 4 
 
 9 
 
 9 
 
 17 
 
 1919 . 
 
 7 
 
 ] 
 
 7 
 
 1 
 
 6 
 
 2 
 
 1 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 among either whites or blacks, the fatality was proportionally nearly three 
 times greater in the white than in the negro race, the number of deaths standing 
 in the ratio of 15 to 1, and the population 5.42 to 1, repectively, a remarkably 
 high shift in favor of the negro since 1850. It is unlikely that such a great 
 difference is to be explained entirely by greater difficulty in diagnosis in the 
 negro. 
 
FEBRILE DISEASES 
 
 305 
 
 The results of calculations to determine the influence of age, sex, and color 
 upon the mortality of scarlet fever in 1910 and 1920 are shown in tables 47 
 and 48. Whereas there are no significant differences between the rates for all 
 ages in males and females of the white and colored races, the total white rate is 
 over four times as great as that for negroes. Owing to the smallness of the 
 number of deaths and the differences in the age-groupings, direct comparison 
 
 Table 47 .—Number of deaths and rate of death, per 100,000 living inhabitants, from 
 scarlet fever and measles, according to age, color, and sex, for 1910. 
 
 SCARLET FEVER. 
 
 D = death. R = rate. 
 
 Age period. 
 
 Total. 
 
 White. 
 
 Colored. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 Total. 
 
 Mal'e. 
 
 Fem. 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 Under 1 year. 
 
 1 
 
 10 
 
 1 
 
 11 
 
 1 
 
 22 
 
 
 
 
 
 
 
 
 
 Between 1 and 2 years 
 
 7 
 
 73 
 
 7 
 
 83 
 
 3 
 
 68 
 
 4 
 
 98 
 
 
 
 
 
 
 
 2 to 4 years. 
 
 23 
 
 72 
 
 22 
 
 79 
 
 13 
 
 92 
 
 9 
 
 65 
 
 1 
 
 24 
 
 1 
 
 50 
 
 • • • 
 
 • • • 
 
 5 to 9 years. 
 
 10 
 
 20 
 
 10 
 
 23 
 
 7 
 
 32 
 
 3 
 
 14 
 
 
 
 
 
 
 
 Under 10 years. 
 
 41 
 
 40 
 
 40 
 
 45 
 
 24 
 
 54 
 
 16 
 
 36 
 
 1 
 
 8 
 
 1 
 
 16 
 
 • • • 
 
 
 10 to 19 years. 
 
 5 
 
 5 
 
 4 
 
 4 
 
 
 
 4 
 
 9 
 
 1 
 
 7 
 
 • • • 
 
 • • • 
 
 1 
 
 13 
 
 20 to 29 years. 
 
 1 
 
 1 
 
 1 
 
 1 
 
 
 
 1 
 
 2 
 
 
 
 
 
 
 
 30 to 39 years. 
 
 1 
 
 1 
 
 1 
 
 J 
 
 
 
 1 
 
 3 
 
 
 
 
 
 
 
 40 to 49 years. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 50 to 59 years. 
 
 1 
 
 2 
 
 1 
 
 3 
 
 
 
 1 
 
 5 
 
 
 
 
 
 
 
 60 years and over.... 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Total . 
 
 49 
 
 9 
 
 47 
 
 10 
 
 24 
 
 10 
 
 23 
 
 9 
 
 2 
 
 2 
 
 1 
 
 3 
 
 1 
 
 2 
 
 MEASLES. 
 
 Under 1 year. 
 
 3 
 
 29 
 
 3 
 
 34 
 
 1 
 
 22 
 
 2 
 
 45 
 
 
 
 
 
 
 
 Between 1 and 2 years 
 
 12 
 
 125 
 
 11 
 
 130 
 
 8 
 
 182 
 
 3 
 
 73 
 
 1 
 
 89 
 
 • • • 
 
 • • • 
 
 1 
 
 175 
 
 2 to 4 years. 
 
 1 
 
 31 
 
 1 
 
 4 
 
 1 
 
 7 
 
 
 
 
 
 
 
 
 
 5 to 9 years. 
 
 1 
 
 2 
 
 1 
 
 2 
 
 1 
 
 5 
 
 
 
 
 
 
 
 
 
 Under 10 years. 
 
 10 to 19 years. 
 
 20 to 29 years. 
 
 30 to 39 years. 
 
 17 
 
 17 
 
 16 
 
 18 
 
 11 
 
 25 
 
 5 
 
 11 
 
 1 
 
 8 
 
 • • • 
 
 • • • 
 
 1 
 
 15 
 
 40 to 49 years. 
 
 50 to 59 years. 
 
 60 years and over.... 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Total . 
 
 17 
 
 3 
 
 16 
 
 3 
 
 11 
 
 5 
 
 5 
 
 2 
 
 1 
 
 1 
 
 • • • 
 
 • • • 
 
 1 
 
 2 
 
 of the relative influence of age in this year and in 1850, as shown in the rates 
 described from Frick’s figures, is difficult. In both tables the great bulk of the 
 deaths occur under the tenth year. 
 
 Though legally reportable since 1882, there are no records of reported cases 
 of scarlet fever before 1893, and it is only since 1897 that case reporting has 
 approached accuracy. The absolute figures of reported cases by months and 
 years and the appropriate rates are presented in table 49. These monthly 
 
306 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 annual and the annual morbidity-rates from 1897 to 1920 may be compared 
 with similar rates for mortality given in table 50. The course of the curves 
 for the morbidity- and mortality-rates during this period corresponds very 
 closely. Such differences as exist are not very significant and are, in large part 
 at least, explained by the lag of deaths behind reported cases. The degree of 
 difference, that is, the variation in the relative heights of the two curves in 
 
 Table 48 .—Number of deaths and rate of death, per 100,000 living inhabitants, from 
 scarlet fever and measles, according to age, color, and sex, for 1920. 
 
 SCARLET FEVER. 
 
 D = death. R = rate. 
 
 
 Total. 
 
 
 
 White. 
 
 
 
 
 
 Colored. 
 
 
 
 Age-groups. 
 
 Total. 
 
 Male. 
 
 Fern. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 Under 1 year. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 to 4 years. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 0 to 4 years. 
 
 8 
 
 12 
 
 8 
 
 13 
 
 4 
 
 13 
 
 4 
 
 9 
 
 
 
 
 
 
 
 5 to 9 years. 
 
 1 
 
 2 
 
 1 
 
 2 
 
 1 
 
 3 
 
 
 
 
 
 
 
 
 
 0 to 9 years. 
 
 9 
 
 7 
 
 9 
 
 8 
 
 5 
 
 8 
 
 4 
 
 7 
 
 
 
 
 
 
 
 10 to 19 years. 
 
 1 
 
 1 
 
 1 
 
 1 
 
 • • • 
 
 • • • 
 
 1 
 
 2 
 
 
 
 
 
 
 
 20 to 29 years. 
 
 2 
 
 1 
 
 2 
 
 2 
 
 • • • 
 
 • • • 
 
 2 
 
 3 
 
 
 
 
 
 
 
 30 to 39 years. 
 
 1 
 
 1 
 
 1 
 
 1 
 
 1 
 
 2 
 
 
 
 
 
 
 
 
 
 40 to 49 years. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 50 to 59 years. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 60 to 69 years. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 70 to 79 years. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 80 years and over.... 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Total . 
 
 13 
 
 2 
 
 13 
 
 2 
 
 6 
 
 2 
 
 7 
 
 2 
 
 
 
 
 
 
 
 MEASLES. 
 
 Under 1 
 
 year. 
 
 12 
 
 81 
 
 10 
 
 78 
 
 6 
 
 91 
 
 4 
 
 64 
 
 2 
 
 101 
 
 1 
 
 104 
 
 1 
 
 99 
 
 1 to 
 
 4 
 
 years. 
 
 34 
 
 62 
 
 30 
 
 62 
 
 17 
 
 70 
 
 13 
 
 54 
 
 4 
 
 62 
 
 2 
 
 64 
 
 2 
 
 61 
 
 0 to 
 
 4 
 
 years. 
 
 46 
 
 66 
 
 40 
 
 66 
 
 23 
 
 75 
 
 17 
 
 39 
 
 6 
 
 72 
 
 3 
 
 74 
 
 3 
 
 70 
 
 5 to 
 
 9 
 
 years. 
 
 3 
 
 5 
 
 3 
 
 5 
 
 2 
 
 7 
 
 1 
 
 4 
 
 
 
 
 
 
 
 0 to 
 
 9 
 
 years. 
 
 49 
 
 37 
 
 43 
 
 37 
 
 25 
 
 42 
 
 18 
 
 31 
 
 6 
 
 36 
 
 3 
 
 38 
 
 3 
 
 35 
 
 10 to 
 
 19 
 
 years. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 20 to 
 
 29 
 
 years. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 30 to 
 
 39 
 
 years. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 40 to 
 
 49 
 
 years. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 50 to 
 
 59 
 
 years. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 60 to 
 
 69 
 
 years. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 70 to 
 
 79 
 
 years. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 80 years 
 
 and over.... 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Total . 
 
 49 
 
 7 
 
 43 
 
 7 
 
 25 
 
 1 
 
 8 
 
 18 
 
 6 
 
 6 
 
 6 
 
 3 
 
 6 
 
 3 
 
 5 
 
 corresponding years, is often marked, and reflects the considerable variation in 
 the annual case-fatality rates. 
 
 Referring to table 49, it will be noted that, beginning in 1897 with a rate 
 of 212 the morbidity-rates declined during the succeeding 4 years to 76 in 1901. 
 Rising then to 92 in 1902 and abruptly to 232 in 1903 and 229 in 1904, they 
 
Table 49 .—Morbidity by months and years and the monthly annual and annual rates of morbidity, per 100,000 living inhabitants, from scarlet fever, 
 
 from 1897 to 1920, inclusive. 
 
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 © 
 
 © 
 
 © 
 
 © 
 
 t— © 
 
 © 
 
 
 © 
 
 © 
 
 Cl 
 
 Feb. 
 
 
 Cl 
 
 rH 
 
 
 
 
 rH 
 
 
 Cl 
 
 rH 
 
 rH 
 
 
 Tit 
 
 rH 
 
 Cl 
 
 Cl 
 
 rH 
 
 Cl 
 
 rH 
 
 © 
 
 Cl 
 
 
 
 © 
 
 Tit 
 
 
 00 
 
 00 
 
 tH 
 
 © 
 
 Cl 
 
 © 
 
 © 
 
 © 
 
 Tf1 
 
 © 
 
 © 
 
 rH 
 
 © 
 
 Tit 
 
 © 
 
 © 
 
 © 
 
 © 
 
 © 
 
 rH 
 
 © 
 
 CD 
 
 rH 
 
 © 
 
 
 o 
 
 00 CO 
 
 CO 
 
 Cl 
 
 © 
 
 Tft 
 
 © 
 
 © 
 
 © 
 
 Tit 
 
 Cl 
 
 © 
 
 Tit 
 
 rH 
 
 rH 
 
 © 
 
 rH 
 
 t'- 
 
 © 
 
 rH 
 
 © 
 
 Tft 
 
 © 
 
 © 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 rH 
 
 
 rH 
 
 rH 
 
 
 rH 
 
 
 rH 
 
 rH 
 
 
 
 © 
 
 Cl 
 
 
 
 00 
 
 CO 
 
 © 
 
 rH 
 
 Cl 
 
 © 
 
 © 
 
 © 
 
 © 
 
 Tit 
 
 © 
 
 © 
 
 Tft 
 
 © 
 
 © 
 
 Cl 
 
 © © 
 
 Tit 
 
 © 
 
 co 
 
 © 
 
 rH 
 
 © 
 
 
 
 CO 
 
 CO 
 
 00 
 
 rH 
 
 Tft 
 
 © 
 
 Cl 
 
 © 
 
 rH 
 
 © 
 
 © 
 
 © 
 
 © 
 
 © 
 
 © 
 
 rH 
 
 Cl 
 
 © 
 
 © 
 
 CD 
 
 © © 
 
 © 
 
 © 
 
 c 
 
 
 ci 
 
 <M 
 
 
 rH 
 
 rH 
 
 
 rH 
 
 © 
 
 Cl 
 
 rH 
 
 
 © 
 
 
 rH 
 
 Cl 
 
 Cl 
 
 Cl 
 
 rH 
 
 © 
 
 © 
 
 
 
 Cl 
 
 © 
 
 Cti 
 
 >"3 
 
 
 05 
 
 05 
 
 00 
 
 © 
 
 Cl 
 
 © 
 
 © © 
 
 CO © 
 
 CO 
 
 Tit 
 
 © 
 
 © 
 
 © 
 
 Cl 
 
 © 
 
 rH 
 
 © 
 
 © 
 
 © 
 
 © 
 
 rH 
 
 
 o 
 
 r-H 
 
 05 
 
 © 
 
 
 © 
 
 Cl 
 
 © © © 
 
 
 Cl 
 
 Tit 
 
 T}t 
 
 © 
 
 Cl 
 
 © 
 
 rH 
 
 
 © 
 
 © 
 
 © 
 
 © 
 
 © 
 
 rH 
 
 
 rH 
 
 
 
 
 
 
 
 rH 
 
 
 
 
 rH 
 
 
 
 rH 
 
 rH 
 
 rH 
 
 
 rH 
 
 rH 
 
 
 
 rH 
 
 
 
 h 
 
 
 00 
 
 © © 
 
 rH 
 
 Cl 
 
 © Tft 
 
 © © co 
 
 © 
 
 © 
 
 rH 
 
 Cl 
 
 © "It 
 
 © 
 
 CD 
 
 OO 
 
 © 
 
 © 
 
 
 
 05 
 
 05 
 
 © 
 
 © 
 
 © 
 
 © 
 
 © 
 
 © 
 
 © 
 
 © 
 
 © 
 
 © 
 
 © 
 
 *H 
 
 rH 
 
 rH 
 
 rH 
 
 rH 
 
 rH 
 
 rH 
 
 rH 
 
 rH 
 
 rH 
 
 Cl 
 
 
 
 00 
 
 00 
 
 00 05 
 
 rH rH 
 
 G C5 O 
 
 rH .—1 H 
 
 © 
 
 © 
 
 © 
 
 © 
 
 © 
 
 © 
 
 © 
 
 05 
 
 © 
 
 05 
 
 rH 
 
 05 
 
 •H 
 
 05 
 
 rH 
 
 05 
 
 rH 
 
 05 
 
 rH 
 
 05 
 
 rH 
 
 05 
 
 rH 
 
 05 
 
 rH 
 
Table 50. —Number of deaths by months and years, and the monthly annual and annual rates of death, per 100,000 living inhabitants, 
 
 scarlet fever, from 1856 to 1920, inclusive. 
 
 D = death. R = rate. 
 
 308 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 
 
 
 50 
 
 00 
 
 CO 
 
 Til 
 
 -*n 
 
 50 
 
 50 
 
 r- 50 
 
 05 
 
 T^ 
 
 05 
 
 Tii 
 
 Tii 
 
 Til 
 
 © 
 
 © 
 
 00 
 
 © 
 
 rH 
 
 rH 
 
 co 
 
 rH 
 
 00 
 
 05 
 
 rH 
 
 © 
 
 00 
 
 • 
 
 
 PS 
 
 rH 
 
 I- CO 
 
 
 50 
 
 rH 
 
 50 
 
 t* 
 
 50 
 
 co 
 
 Ttl 
 
 50 
 
 Tii 
 
 © 
 
 © 
 
 05 
 
 Tii 
 
 co 
 
 
 00 
 
 Tii 
 
 Tii 
 
 rH 
 
 rH 
 
 © 
 
 50 © 
 
 05 
 
 
 
 
 rH 
 
 rH 
 
 05 
 
 rH 
 
 
 rH 
 
 05 
 
 rH 
 
 
 
 
 
 
 
 
 05 
 
 
 
 
 rH 
 
 rH 
 
 rH 
 
 
 rH 
 
 rH 
 
 
 
 
 
 "o 
 
 Lh 
 
 
 
 05 
 
 co 
 
 50 
 
 rH 
 
 CO 
 
 05 
 
 50 05 CO 
 
 CO 
 
 rH 
 
 r— 
 
 
 rH 
 
 © 
 
 50 
 
 i—l 50 Ttl 
 
 © 
 
 05 
 
 t- 
 
 rH 
 
 
 © 
 
 50 
 
 © 
 
 Tii 
 
 Tii 
 
 
 
 Q 
 
 (M 
 
 50 CO 
 
 o 
 
 rH 
 
 50 
 
 r- co 
 
 co 
 
 00 
 
 05 
 
 co 
 
 05 
 
 t- 
 
 50 
 
 05 
 
 Tii 
 
 rH 
 
 co 
 
 rH 
 
 © 
 
 tH 
 
 Til 
 
 © 
 
 © 
 
 rH 
 
 t— 
 
 CO 
 
 © 
 
 
 
 
 05 
 
 CO >0 CO 
 
 rH 
 
 05 
 
 50 
 
 co 
 
 rH 
 
 
 rH 
 
 rH 
 
 rH 
 
 rH 
 
 05 
 
 © 
 
 rH 
 
 rH 
 
 05 
 
 50 
 
 50 
 
 Til 
 
 rH 
 
 CO 
 
 Tii 
 
 05 
 
 rH 
 
 CO 
 
 rH 
 
 
 
 PS 
 
 05 
 
 tH 
 
 05 
 
 CO 
 
 CO 
 
 GO 
 
 co 
 
 o 
 
 05 
 
 >o 
 
 00 
 
 CO 
 
 r— 
 
 © 
 
 CO 
 
 00 t'- © 
 
 05 
 
 © 
 
 © 
 
 co 
 
 Tii 
 
 © 
 
 rH 
 
 
 
 
 
 rH 
 
 50 
 
 05 t— 05 
 
 05 
 
 05 
 
 05 
 
 CO 
 
 
 05 
 
 05 
 
 rH 
 
 © 
 
 05 
 
 © r- © 
 
 © 
 
 00 
 
 CO 
 
 50 t— CO 
 
 Til 
 
 © 
 
 Til 
 
 
 Dec. 
 
 
 
 C5 
 
 1—1 CO 
 
 
 
 T* 
 
 rH 
 
 
 
 
 
 
 rH 
 
 
 05 
 
 
 
 
 05 
 
 l—l CO 
 
 
 
 rH 
 
 rH 
 
 
 
 
 
 
 CO 
 
 co t— co 
 
 
 O 
 
 t— 
 
 05 
 
 05 
 
 O 
 
 O CO 
 
 50 
 
 05 
 
 rH 
 
 50 
 
 © 
 
 Tii 
 
 CO 
 
 
 05 
 
 50 
 
 © 
 
 © 
 
 © 
 
 05 
 
 © 50 © 
 
 
 
 Q 
 
 CO 
 
 05 
 
 50 
 
 iH 
 
 rH 
 
 00 CO 
 
 rH 
 
 rH 
 
 rH 
 
 05 
 
 
 05 
 
 05 
 
 50 
 
 rH 
 
 rH 
 
 05 
 
 50 
 
 Tii 
 
 o 
 
 rH 
 
 rH 
 
 05 
 
 Til 
 
 co 
 
 rH 
 
 05 
 
 rH 
 
 
 
 
 
 o 
 
 05 
 
 00 
 
 rH 
 
 00 
 
 CO 
 
 o 
 
 o 
 
 CO 
 
 50 
 
 Ttl 
 
 CO t- 
 
 © 
 
 05 
 
 05 
 
 50 
 
 © 
 
 50 
 
 05 
 
 00 CO 
 
 © 
 
 05 
 
 © 
 
 00 
 
 >o 
 
 
 r— 
 
 
 
 PS 
 
 05 
 
 50 
 
 05 
 
 t* 
 
 CO 
 
 CO 
 
 o 
 
 o 
 
 co 
 
 50 
 
 t* CO 
 
 rH 
 
 rH 
 
 50 
 
 50 
 
 50 
 
 05 
 
 50 
 
 CO 
 
 00 
 
 
 IONH 
 
 05 CO tr. 
 
 rH 
 
 > 
 
 
 
 rH 
 
 rH 
 
 CO 
 
 
 
 rH 
 
 05 
 
 rH 
 
 
 
 
 
 rH 
 
 rH 
 
 rH 
 
 
 
 
 rH 
 
 rH 
 
 rH 
 
 
 
 rH 
 
 rH 
 
 
 
 
 
 £ 
 
 
 
 05 CO 
 
 50 r^ 05 
 
 O t" 
 
 rH 
 
 i—l 05 
 
 00 
 
 50 
 
 © 
 
 Til 
 
 05 
 
 CO 
 
 t- 
 
 OO CO 
 
 00 
 
 © 
 
 50 
 
 t". CO 
 
 OO 
 
 © 
 
 05 
 
 50 
 
 
 
 Q 
 
 rH 
 
 05 
 
 50 
 
 
 rH 
 
 CO 
 
 CO 
 
 05 
 
 
 rH 
 
 
 
 05 
 
 05 
 
 CO 
 
 rH 
 
 rH 
 
 
 CO 
 
 CO 
 
 Tii 
 
 rH 
 
 rH 
 
 Tii 
 
 co 
 
 
 rH 
 
 05 
 
 
 
 
 o 
 
 rH 
 
 Tt5 
 
 05 CO 
 
 o 
 
 CO 
 
 rH 
 
 o 
 
 Ttl 
 
 
 05 
 
 co 
 
 rH 
 
 50 
 
 CO 
 
 © 
 
 © 
 
 CO 
 
 05 
 
 00 
 
 Tii 
 
 00 
 
 
 rH 
 
 rH 
 
 © 
 
 CO 
 
 © 
 
 
 
 PS 
 
 rH 
 
 o 
 
 O 
 
 CO 
 
 CO 
 
 *o 
 
 00 
 
 co 
 
 05 
 
 CO 
 
 50 co 
 
 oo co 
 
 © 
 
 © 
 
 50 i—l 
 
 © 
 
 rH 
 
 © 
 
 Tii 
 
 50 
 
 rH 
 
 00 
 
 Til 
 
 Tii 
 
 Tii 
 
 rH 
 
 *4-2 
 
 
 rH 
 
 rH 
 
 TJ5 
 
 
 
 rH 
 
 rH 
 
 
 
 
 
 
 
 
 
 
 
 
 
 rH 
 
 
 
 
 rH 
 
 rH 
 
 
 
 
 
 O 
 
 
 
 CO t" 
 
 o 
 
 rH 
 
 00 50 CO 
 
 4 
 
 7 
 
 2 
 
 7 
 
 9 
 
 7 
 
 5 
 
 >o 
 
 05 
 
 Tii 
 
 © 
 
 © © 
 
 05 
 
 © 
 
 CO 
 
 05 
 
 05 
 
 05 
 
 co co 
 
 
 
 a 
 
 rH 
 
 rH 
 
 t- 
 
 rH 
 
 rH 
 
 05 
 
 co 
 
 
 
 
 rH 
 
 
 rH 
 
 
 rH 
 
 rH 
 
 rH 
 
 
 rH 
 
 05 
 
 05 
 
 rH 
 
 rH 
 
 CO 
 
 50 
 
 rH 
 
 rH 
 
 rH 
 
 
 
 
 
 05 
 
 »o 
 
 CO 
 
 05 
 
 r- 
 
 o 
 
 CO 
 
 00 
 
 o 
 
 o 
 
 o 
 
 05 
 
 50 50 05 
 
 © 
 
 rH 
 
 rH 
 
 rH 
 
 05 
 
 Tii 
 
 © 
 
 Til 
 
 © 
 
 rH 
 
 oo 
 
 50 
 
 © 
 
 
 
 PS 
 
 CO 
 
 50 
 
 05 
 
 50 
 
 rH 
 
 50 
 
 T* 
 
 CO 
 
 r-l CO 
 
 05 
 
 l—l CO 
 
 50 Tii r- 
 
 00 
 
 05 
 
 © 
 
 CO 50 
 
 CO 
 
 rH 
 
 00 
 
 05 
 
 05 
 
 05 
 
 rH 
 
 -4-> 
 
 Q, 
 
 
 rH 
 
 
 05 
 
 
 
 rH 
 
 iH 
 
 
 
 
 
 
 
 
 
 
 
 
 
 rH 
 
 
 
 
 rH 
 
 
 
 
 rH 
 
 
 <D 
 
 C Q 
 
 
 
 i-5 05 05 
 
 05 CO t— 
 
 
 50 
 
 05 CO 
 
 T* 
 
 Til 
 
 Til 
 
 05 
 
 rH 
 
 © 
 
 © 
 
 50 50 
 
 CO 
 
 © 
 
 CO 
 
 © 
 
 05 
 
 Tii 
 
 © 
 
 00 
 
 i— co 
 
 
 Q 
 
 05 
 
 
 tH 
 
 
 
 05 
 
 05 
 
 rH 
 
 
 
 
 
 rH 
 
 rH 
 
 rH 
 
 rH 
 
 rH 
 
 
 r-l CO 
 
 rH 
 
 rH 
 
 
 co 
 
 05 
 
 
 
 CO 
 
 
 
 
 
 rH 
 
 05 t— Tti 
 
 co 
 
 05 
 
 t— CO 
 
 O 
 
 Ttl 
 
 rH 
 
 CO 
 
 Til 
 
 00 Ttl 
 
 © 
 
 © 
 
 50 
 
 05 
 
 
 rH 
 
 © 
 
 Til 
 
 OO 
 
 t- 
 
 1-T- 
 
 05 
 
 05 
 
 
 
 PS 
 
 CO 
 
 Tt5 
 
 r- 05 
 
 rH 
 
 50 
 
 CO 
 
 CO 
 
 rH 
 
 05 
 
 t— 
 
 rH 
 
 co th 
 
 rH 
 
 05 
 
 05 
 
 50 
 
 rH 
 
 rH 
 
 oo 
 
 © 
 
 05 
 
 © 
 
 05 
 
 Tii 
 
 
 05 
 
 fcjD 
 
 
 
 
 05 
 
 rH 
 
 
 
 rH 
 
 
 
 
 
 
 
 
 
 rH 
 
 
 
 
 rH 
 
 rH 
 
 
 
 rH 
 
 rH 
 
 
 
 
 
 H 
 
 
 
 o 
 
 tr- 
 
 00 
 
 05 
 
 CO 
 
 rH 
 
 05 
 
 CO 
 
 05 
 
 50 50 
 
 co 
 
 00 
 
 © 
 
 00 O- O- 50 Til © 
 
 rH 
 
 05 
 
 © 
 
 »o 
 
 rH 
 
 00 
 
 Til 
 
 05 
 
 
 
 
 Q 
 
 rH 
 
 
 Ttl 
 
 05 
 
 
 rH 
 
 co 
 
 rH 
 
 
 
 rH 
 
 
 
 rH 
 
 i-l 05 
 
 
 
 rH 
 
 05 
 
 co 
 
 05 
 
 i-H CO 
 
 co 
 
 
 rH 
 
 05 
 
 
 
 
 Ph 
 
 *o 
 
 05 
 
 CO 
 
 CO 
 
 00 
 
 00 
 
 05 
 
 r- 
 
 o 
 
 50 
 
 rH 
 
 co 
 
 05 
 
 Tii 
 
 00 
 
 05 
 
 05 
 
 © © © 
 
 © 
 
 © 
 
 © 
 
 rH 
 
 50 Ttl 
 
 © 
 
 
 © 
 
 
 
 00 
 
 rH 
 
 co t— co 
 
 Ttl 
 
 05 
 
 rH 
 
 CO 
 
 rH 
 
 t— 
 
 Tjl 
 
 
 tH 
 
 r- co 
 
 r-l CO 
 
 CO 
 
 © t- © 
 
 Tii 
 
 05 
 
 05 
 
 05 
 
 co © 
 
 rH 
 
 
 
 
 
 rH 
 
 H 
 
 
 
 
 05 
 
 rH 
 
 
 
 
 
 
 
 
 05 
 
 
 
 
 rH 
 
 
 
 
 rH 
 
 rH 
 
 
 
 
 
 
 
 
 T* 
 
 o 
 
 co 
 
 CO t" 05 
 
 © 
 
 CO 
 
 CO CO 
 
 50 
 
 o 
 
 05 
 
 © 
 
 00 
 
 50 
 
 CO 
 
 © © CO 
 
 i-h © 
 
 rH ^ 
 
 © 
 
 t'- © 
 
 © 
 
 50 
 
 
 
 Q 
 
 rH 
 
 05 
 
 05 
 
 rH 
 
 
 
 50 
 
 05 
 
 
 
 rH 
 
 rH 
 
 
 rH 
 
 rH 
 
 50 
 
 
 
 
 tH 
 
 05 
 
 05 
 
 i-h co 
 
 CO 
 
 
 
 rH 
 
 
 
 
 
 CO 
 
 00 
 
 05 
 
 
 CO 
 
 CO 
 
 rH 
 
 o 
 
 rH 
 
 50 
 
 t* 
 
 co 
 
 05 
 
 rH 
 
 Ttl 
 
 © 
 
 CO 
 
 05 
 
 © 
 
 00 
 
 © 
 
 © 
 
 05 
 
 © 
 
 Til 
 
 CO 
 
 05 
 
 50 
 
 CO 
 
 
 
 PS 
 
 rH 
 
 05 
 
 rH 
 
 CO 
 
 05 
 
 CO 
 
 00 
 
 05 
 
 50 
 
 rH 
 
 50 
 
 Til 
 
 Tii 
 
 tH 
 
 »o 
 
 Ttl 
 
 rH 
 
 Tii 
 
 © 
 
 oo 
 
 © 
 
 oo »o 
 
 © 
 
 © 
 
 50 
 
 © 
 
 05 
 
 50 
 
 o 
 
 a 
 
 
 rH 
 
 
 rH 
 
 
 
 
 05 
 
 rH 
 
 
 
 
 
 
 
 
 05 
 
 
 
 
 rH 
 
 
 rH 
 
 
 
 rH 
 
 
 
 rH 
 
 
 3 
 
 ►“3 
 
 
 
 00 CO 
 
 o 
 
 rH 50 05 
 
 05 
 
 00 
 
 o 
 
 CO 
 
 rH 
 
 05 
 
 05 05 
 
 05 
 
 50 
 
 CO 
 
 © t'» t— co 
 
 t- Tii 
 
 i— © 
 
 50 
 
 oo © 
 
 
 
 o 
 
 rH 
 
 rH 
 
 05 
 
 rH 
 
 
 rH 
 
 50 
 
 co 
 
 rH 
 
 
 rH 
 
 
 
 
 rH 
 
 50 
 
 
 rH 
 
 rH 
 
 Tii 
 
 05 
 
 Tii 
 
 i—1 05 
 
 05 
 
 rH 
 
 rH 
 
 CO 
 
 rH 
 
 
 
 PS 
 
 tH 
 
 00 
 
 o 
 
 H N « N M 
 
 05 T* 
 
 05 
 
 CO 
 
 CO 
 
 © © 
 
 00 Til 
 
 rH 
 
 ©ONN 
 
 50 Til 
 
 00 
 
 00 
 
 © 
 
 00 
 
 rH 
 
 
 
 CO 
 
 rt5 
 
 05 
 
 Ttl 
 
 05 
 
 ■<ii t- t* 
 
 00 co 
 
 rH 
 
 »o CO 
 
 00 
 
 50 
 
 rH 
 
 50 © 
 
 50 © 
 
 l—l CO 
 
 05 
 
 rH 
 
 © 
 
 Ttl 
 
 © 
 
 05 
 
 50 
 
 >> 
 
 d 
 
 
 
 rH 
 
 iH 
 
 05 
 
 rH 
 
 
 
 05 
 
 rH 
 
 
 
 
 
 
 
 
 Til 
 
 
 
 
 rH 
 
 rH 
 
 rH 
 
 
 rH 
 
 rH 
 
 
 
 rH 
 
 a 
 
 
 
 05 
 
 r*5 
 
 00 50 50 
 
 00 CO 
 
 CO 
 
 00 Til 
 
 05 
 
 00 CO CO 
 
 © 
 
 co 
 
 50 
 
 50 CO 
 
 i—i 05 
 
 rH 
 
 Til 
 
 00 © 
 
 © 
 
 
 
 Q 
 
 05 
 
 05 
 
 CO 
 
 05 
 
 
 
 50 
 
 05 
 
 rH 
 
 
 
 rH 
 
 
 rH 
 
 r-l © 
 
 rH 
 
 rH 
 
 rH Til 
 
 co co 
 
 
 CO 
 
 CO 
 
 rH 
 
 l—l CO 
 
 rH 
 
 
 
 
 CO 
 
 CO 
 
 50 
 
 00 
 
 i—l tH 
 
 CO t"- 05 
 
 50 05 
 
 rH 
 
 05 th 
 
 00 CO 
 
 © 
 
 50 05 
 
 © 
 
 © 
 
 © 
 
 
 rH 
 
 Tii 
 
 fr- 
 
 50 
 
 r- 
 
 
 
 PS 
 
 05 
 
 05 
 
 00 
 
 05 
 
 05 
 
 05 
 
 l—l CO 05 
 
 l-H CO 
 
 05 tJI CO 
 
 © 
 
 rH 
 
 Tii 
 
 50 
 
 Til 
 
 © r^- r- 
 
 rH 
 
 
 © 
 
 t- 
 
 © 
 
 © 
 
 rH 
 
 
 
 
 rH 
 
 iH 
 
 rH 
 
 rH 
 
 
 
 CO 
 
 rH 
 
 
 
 
 
 
 
 
 co 
 
 
 
 
 rH 
 
 rH 
 
 rH 
 
 
 
 rH 
 
 
 rH 
 
 
 
 < 
 
 
 
 o 
 
 05 
 
 l—l Ttl 
 
 CO 
 
 
 00 
 
 00 
 
 00 
 
 CO 
 
 00 
 
 05 05 
 
 00 
 
 rH CO 
 
 © 
 
 05 
 
 rH 
 
 00 
 
 50 
 
 © 
 
 50 i—1 
 
 00 
 
 rH 
 
 rH 
 
 00 
 
 50 
 
 
 
 Q 
 
 05 
 
 co co 
 
 CO 
 
 rH 
 
 rH 
 
 50 
 
 05 
 
 rH 
 
 
 
 rH 
 
 
 
 05 r~ i—i 
 
 rH 
 
 rH 
 
 TH 
 
 Til 
 
 Til 
 
 
 05 
 
 05 
 
 05 
 
 co 
 
 05 
 
 
 
 
 05 
 
 00 
 
 05 
 
 50 50 t- 
 
 00 
 
 © 
 
 o 
 
 T* 
 
 05 50 
 
 50 05 
 
 05 
 
 Til 
 
 50 »© 
 
 © 
 
 © 
 
 r- 
 
 © 
 
 © 
 
 
 00 
 
 © 
 
 rH 
 
 rH 
 
 
 
 PS 
 
 05 
 
 o 
 
 05 
 
 CO 
 
 50 
 
 05 
 
 o 
 
 CO 
 
 oo co 
 
 
 05 
 
 
 © 
 
 00 tr- Til 
 
 Tii 
 
 50 
 
 00 
 
 © 
 
 © 
 
 05 
 
 © r- 
 
 © 
 
 50 
 
 05 
 
 50 
 
 Mar. 
 
 
 
 rH 
 
 CO 
 
 Ttl 
 
 05 
 
 
 
 CO 
 
 05 
 
 
 
 
 rH 
 
 
 
 
 05 
 
 
 
 
 rH 
 
 05 
 
 05 
 
 
 
 
 
 
 rH 
 
 
 
 o 
 
 05 
 
 co t- 
 
 o 
 
 50 05 
 
 rH 
 
 CO 
 
 t- 05 t- 
 
 rH 
 
 Til 
 
 © 
 
 50 
 
 rH 
 
 05 
 
 50 
 
 00 
 
 © 
 
 05 
 
 oo r- 
 
 05 
 
 © 
 
 50 
 
 r— © 
 
 
 
 Q 
 
 05 
 
 50 
 
 rH 
 
 
 50 
 
 50 
 
 rH 
 
 
 
 05 
 
 
 rH 
 
 rH 
 
 © 
 
 rH 
 
 rH 
 
 rH 
 
 Tii 
 
 
 
 
 05 
 
 05 
 
 05 
 
 i-l CO 
 
 rH 
 
 
 
 PS 
 
 r— 
 
 o 
 
 co 
 
 CO 
 
 05 
 
 05 
 
 00 
 
 rH 
 
 00 
 
 00 
 
 rH 
 
 05 
 
 © 
 
 CO 
 
 05 
 
 00 
 
 © 
 
 05 
 
 © 
 
 l" © 
 
 © 
 
 Til 
 
 rH 
 
 © 
 
 © 
 
 Tii 
 
 Til 
 
 05 
 
 
 
 TH 
 
 TH 
 
 Tti 
 
 05 
 
 r- 
 
 50 
 
 50 
 
 r- 
 
 CO 
 
 co 
 
 co 
 
 05 
 
 rH 
 
 © t '- 
 
 OO 
 
 50 05 © 
 
 50 
 
 00 
 
 50 
 
 05 
 
 I*- 
 
 rH 
 
 05 
 
 Til 
 
 CO 
 
 CO 
 
 Feb. 
 
 
 
 
 TJ5 
 
 05 
 
 05 
 
 
 
 CO 
 
 05 
 
 rH 
 
 
 
 
 
 
 
 co 
 
 
 
 
 05 
 
 05 
 
 05 
 
 
 
 rH 
 
 rH 
 
 
 rH 
 
 
 
 
 
 00 
 
 t" 
 
 co 
 
 o 
 
 05 
 
 00 
 
 50 co 
 
 00 
 
 IN 
 
 © 
 
 50 CO CO 
 
 50 50 
 
 © 
 
 © 
 
 rH 
 
 © 
 
 00 
 
 rH 
 
 T* 
 
 05 r~~ 
 
 © 
 
 
 
 Q 
 
 
 CO co 
 
 TJH 
 
 rH 
 
 rH 
 
 CO 
 
 Ttl 
 
 05 
 
 
 
 rH 
 
 
 rH 
 
 1-1 00 
 
 rH 
 
 
 rH 
 
 © 
 
 © 
 
 © 
 
 
 i—i co 
 
 CO 
 
 rH 
 
 co 
 
 
 
 PS 
 
 
 00 
 
 rH 
 
 05 
 
 rH 
 
 o 
 
 o 
 
 o 
 
 o 
 
 co 
 
 rH 
 
 50 
 
 CO 
 
 rH 
 
 50 
 
 Til 
 
 Tii 
 
 oo co 
 
 00 t— 
 
 >o 
 
 © 
 
 CO 
 
 CO 
 
 00 
 
 © 
 
 05 
 
 05 
 
 
 
 O CO 
 
 05 
 
 T* 
 
 i- 
 
 00 
 
 50 
 
 50 
 
 00 
 
 00 t" CO 
 
 05 
 
 r- 05 
 
 © t- 05 
 
 © 
 
 05 
 
 »o 
 
 00 
 
 tH 
 
 Til 
 
 50 
 
 © 
 
 Tii 
 
 © 
 
 Tii 
 
 Jan. 
 
 
 
 1-5 CO 
 
 i—l CO 
 
 
 
 CO 
 
 05 
 
 
 
 
 
 
 
 rH 
 
 Tii 
 
 
 
 
 05 
 
 05 
 
 05 
 
 
 
 rH 
 
 rH 
 
 
 
 
 
 
 CO 
 
 05 
 
 CO 
 
 50 t— 
 
 05 
 
 CO t— 
 
 50 
 
 Til 
 
 50 
 
 © 
 
 © 
 
 © 
 
 00 !>• © 
 
 © 
 
 00 
 
 r- 
 
 rH 
 
 05 
 
 Tji 
 
 00 
 
 05 
 
 00 CO 
 
 
 
 Q 
 
 rH 
 
 50 
 
 co 
 
 CO 
 
 rH 
 
 rH 
 
 CO 
 
 Tt 
 
 rH 
 
 rH 
 
 rH 
 
 rH 
 
 
 rH 
 
 05 
 
 rH 
 
 rH 
 
 rH 
 
 
 rH 50 © 
 
 rH 
 
 rH 
 
 Til 
 
 50 
 
 rH 
 
 05 
 
 rH 
 
 Year. 
 
 • 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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 • 
 
 • 
 
 tONCOOlOHINM^UfJONOOffiOHNCO^lOfflNQOaiOHINM^ 
 50505050©©©©©©©©© ONt^NNNt.Nf'NNOOOOOOOOOO 
 
 coaooooooooooocoooaooooooo ooooooooooooooaoaooooooooooooooo 
 
FEBRILE DISEASES 
 
 309 
 
 00 
 
 00 
 
 C5 
 
 o 
 
 
 o 
 
 C5 
 
 r- oo 
 
 oo co 
 
 CO 
 
 rH 05 
 
 5 
 
 4 
 
 ©5 
 
 t- 
 
 CO 
 
 t" CO 
 
 05 
 
 co co 
 
 Hi 
 
 9 
 
 8 
 
 4 
 
 7 
 
 7 
 
 5 
 
 »co 
 
 ©1 
 
 rH 
 
 Hi 
 
 ©i 
 
 rH 
 
 
 
 rH 
 
 rH 
 
 rH 
 
 ©1 
 
 ICO 
 
 
 rH r-H 
 
 
 rH 
 
 
 
 
 
 rH 
 
 ©1 
 
 
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310 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 fell by gradual stages to 79 in 1907. Rebounding sharply to 243 in 1908, the 
 course heretofore pursued was abandoned, and the rate dropped abruptly to 
 81 in 1909. The course of the disease, as judged by its behavior in calendar 
 years, was modified again, when the rate rose to 205 in 1910, and fell the next 
 year to 193, and in 1912 to 128. After rising to 193 in 1913, and falling to 
 135 in 1914, the rate ascended to 211 in 1915. Again there was a change in 
 the course of the disease. Instead of ascending and declining in alternate years, 
 as had been the habit since 1912, the rate now dropped abruptly for three suc¬ 
 cessive years, and in 1918 reached the unusually low level of 59, the lowest 
 recorded morbidity incidence. In 1919, with a suddenly renewed vigor of 
 attack, the rate rose to the remarkably high level of 535. The considerable 
 drop in 1920 to 170 left the r.°te appreciably higher than the average. 
 
 When the course of morbidity during these 24 years is measured by rates 
 averaged for 5-year periods, it is seen (table 49) that from the comparatively 
 low level of 124 for 1897-1900 (4 years) it increased to 149 for 1901-1905, 
 remained stationary at 143 for 1906-1910, and rose considerably to 172 for 
 1911-1915 and to 212 for 1916-1920. During this period the mortality-rates 
 averaged for the same periods pursued quite a different course. Rising out of 
 all proportion to the rise in the morbidity-rates from 7 for the first period to 
 12 for the second, they fell to 7 for the third period, when the morbidity-rates 
 were stationary, and during the remaining periods declined continuously to 3 
 in 1920, in the face of constantly rising morbidity-rates. The case fatality 
 rates similarly averaged fell from 6 per cent to 2 per cent. Thus the striking 
 spectacle is presented of a rise in the incidence of attack by 58 per cent and 
 declines in the death-rate by 57 per cent and in the case-fatality rate by 
 67 per cent. 
 
 For the sake of comparison it will be profitable to form some approximate 
 estimate of what, on the basis of recent case-fatality experience, the morbidity 
 would have been when the mortality was much higher. For this purpose, as 
 examples of the highest and lowest average case-fatality rates of recent experi¬ 
 ence, those of 1901-1905, 7 per cent, and those of 1916-1920, 2 per cent, will 
 be taken. As sample years with high death-rates, 1850 and 1871, when the 
 deaths numbered 225 and 625, and the population numbered 163,930 and 
 278,932, respectively, will serve. On this basis, in 1850 the higher case inci¬ 
 dence would have been 11,250, or a morbidity-rate of 6,863, and the lower 3,214, 
 or a morbidity-rate of 1,961; in 1871, the higher case incidence would have 
 been 31,250 with a morbidity-rate of 11,203, and the lower, 8,929, or a mor¬ 
 bidity-rate of 3,201. The mortality-rates were 137 in 1850 and 224 in 1871. 
 Expressed otherwise, calculated on the basis of the population under 10 years 
 of age, in 1850 the higher case incidence would have equaled 1 in every 4 and 
 the lower 1 in every 13; in 1871, the former would have equaled 1 in every 2 
 and the latter 1 in every 7. When these figures are compared with those of 
 recent experience, and particularly with that of 1919, when the morbidity-rate 
 was 535, the mortality-rate was 2, and the percentage of case-fatality was 
 0.78, the actual occurrence of any such rates of incidence of scarlet fever as 
 those deduced for 1850 and 1871 seems impossible. Taking into account the 
 fact that for more than 20 years before 1871 very high mortality-rates had 
 been in almost constant vogue, on any low percentage of case-fatality there 
 
FEBRILE DISEASES 
 
 311 
 
 could hardly have been a sufficient number of susceptibles in the population to 
 permit such a high case incidence for a disease in which one attack as a rule 
 confers lasting immunity. Therefore, the conclusion is unavoidable that during 
 the period of high mortality the morbidity-rate must have been relatively low 
 
 Table 51. —Number of cases and the rate of morbidity, per 100,000 living inhabitants in 
 1920, from scarlet fever and measles, according to age, color, and sex, for 1921. 
 
 SCARLET FEVER. 
 
 O = cases. R = rate. 
 
 Age-groups. 
 
 Total. 
 
 White. 
 
 Colored. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 C 
 
 R 
 
 C 
 
 R 
 
 C 
 
 R 
 
 1 
 
 C 
 
 R 
 
 C 
 
 R 
 
 C 
 
 R 
 
 C 
 
 R 
 
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 7 
 
 47 
 
 6 
 
 47 
 
 2 
 
 30 
 
 4 
 
 64 
 
 1 
 
 51 
 
 • • • 
 
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 1 
 
 99 
 
 1 to 4 years. 
 
 238 
 
 437 
 
 233 
 
 484 
 
 119 
 
 493 
 
 114 
 
 476 
 
 5 
 
 78 
 
 3 
 
 96 
 
 2 
 
 61 
 
 0 to 4 years. 
 
 245 
 
 353 
 
 239 
 
 392 
 
 121 
 
 394 
 
 118 
 
 272 
 
 6 
 
 72 
 
 3 
 
 74 
 
 3 
 
 70 
 
 5 to 9 years. 
 
 481 
 
 746 
 
 459 
 
 813 
 
 210 
 
 735 
 
 249 
 
 894 
 
 22 
 
 273 
 
 14 
 
 363 
 
 8 
 
 190 
 
 0 to 9 years. 
 
 726 
 
 542 
 
 698 
 
 595 
 
 331 
 
 558 
 
 367 
 
 632 
 
 28 
 
 170 
 
 17 
 
 214 
 
 11 
 
 129 
 
 10 to 19 years. 
 
 261 
 
 211 
 
 249 
 
 231 
 
 108 
 
 204 
 
 141 
 
 257 
 
 12 
 
 75 
 
 10 
 
 141 
 
 2 
 
 22 
 
 20 to 29 years. 
 
 64 
 
 44 
 
 62 
 
 52 
 
 27 
 
 46 
 
 35 
 
 58 
 
 2 
 
 8 
 
 1 
 
 8 
 
 1 
 
 7 
 
 30 to 39 years. 
 
 11 
 
 9 
 
 11 
 
 11 
 
 7 
 
 14 
 
 4 
 
 8 
 
 
 
 
 
 
 
 40 to 49 years. 
 
 2 
 
 2 
 
 2 
 
 3 
 
 • • • 
 
 • • • 
 
 2 
 
 5 
 
 
 
 
 
 
 
 50 to 59 years. 
 
 1 
 
 2 
 
 1 
 
 2 
 
 • • • 
 
 • • • 
 
 1 
 
 4 
 
 
 
 
 
 
 
 Total . 
 
 1065 
 
 145 
 
 1023 
 
 164 
 
 473 
 
 153 
 
 550 
 
 174 
 
 42 
 
 39 
 
 28 
 
 53 
 
 14 
 
 25 
 
 MEASLES. 
 
 Age-groups. 
 
 Total. 
 
 White. 
 
 Colored. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 C 
 
 R 
 
 C 
 
 R 
 
 C 
 
 R 
 
 C 
 
 R 
 
 C 
 
 R 
 
 C 
 
 R 
 
 C 
 
 R 
 
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 75 
 
 505 
 
 72 
 
 559 
 
 33 
 
 500 
 
 39 
 
 621 
 
 3 
 
 152 
 
 1 
 
 104 
 
 2 
 
 198 
 
 1 to 4 years. 
 
 813 
 
 1492 
 
 800 
 
 1663 
 
 425 
 
 1760 
 
 375 
 
 1566 
 
 13 
 
 203 
 
 7 
 
 225 
 
 6 
 
 182 
 
 0 to 4 years. 
 
 888 
 
 1280 
 
 872 
 
 1430 
 
 458 
 
 1490 
 
 414 
 
 955 
 
 16 
 
 191 
 
 8 
 
 197 
 
 8 
 
 186 
 
 5 to 9 years. 
 
 1164 
 
 1805 
 
 1132 
 
 2006 
 
 571 
 
 1998 
 
 561 
 
 2015 
 
 32 
 
 397 
 
 12 
 
 311 
 
 20 
 
 475 
 
 0 to 9 years. 
 
 2052 
 
 1533 
 
 2004 
 
 1707 
 
 1029 
 
 1734 
 
 975 
 
 1679 
 
 48 
 
 292 
 
 20 
 
 252 
 
 28 
 
 329 
 
 10 to 19 years. 
 
 141 
 
 114 
 
 137 
 
 127 
 
 69 
 
 131 
 
 68 
 
 124 
 
 4 
 
 25 
 
 • • • 
 
 • • • 
 
 4 
 
 45 
 
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 29 
 
 20 
 
 27 
 
 23 
 
 13 
 
 22 
 
 14 
 
 23 
 
 2 
 
 8 
 
 1 
 
 8 
 
 1 
 
 7 
 
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 9 
 
 7 
 
 8 
 
 8 
 
 5 
 
 10 
 
 3 
 
 6 
 
 1 
 
 5 
 
 • • • 
 
 • • • 
 
 1 
 
 9 
 
 40 to 49 years. 
 
 2 
 
 2 
 
 2 
 
 3 
 
 1 
 
 3 
 
 1 
 
 3 
 
 
 
 
 
 
 
 50 to 59 years. 
 
 3 
 
 5 
 
 3 
 
 5 
 
 2 
 
 7 
 
 1 
 
 4 
 
 
 
 
 
 
 
 Xot^l • • • • 
 
 2236 
 
 305 
 
 2181 
 
 349 
 
 1119 
 
 363 
 
 106 
 
 2335 
 
 55 
 
 51 
 
 21 
 
 39 
 
 34 
 
 61 
 
 and the case-fatality comparatively high, as compared with the experience of 
 the last 20 years, when the reverse has held. It seems evident, therefore, that 
 as the lethal force of scarlet fever has diminished, its invasive capacity has 
 increased. 
 
 Morbidity-rates specific for color, sex, and age, in 1921 are given in table 51. 
 Two-thirds of the reported cases were in individuals under the tenth year, and 
 
312 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 of the remainder comparatively few were above the twentieth year of age. 
 As with measles, the attack-rate was notably higher among whites than among 
 negroes in every age-group, and in both races the incidence was greater during 
 the second than during the first five years of life. 
 
 From a study of the monthly annual mortality-rates (table 49) and mor¬ 
 bidity-rates (table 50) it is clear that, as a general rule, the incidence and 
 fatality of scarlet fever are lowest in the warm months and highest in the colder 
 months. In typical years these rates are lowest in June, July, August, and 
 September, gradually increase through October, November, December, and 
 January, to a peak reached in January or February, and then as gradually 
 decline. The ascent and the decline in the rates are by no means always so 
 gradual and uninterrupted. While the course of the curves for morbidity 
 
 Table 52.— Maximum and minimum incidence of mortality and morbidity from scarlet 
 fever, by months, from 1856 to 1899, inclusive, and from 1897 to 1920, inclusive, 
 respectively, and the percentage of each to the total number of years. 
 
 Months. 
 
 Months in 34 
 years in which 
 maximum 
 mortality-rate 
 obtains. 
 
 Months in 34 
 years in which 
 minimum 
 mortality-rate 
 obtains. 
 
 Months in 24 
 years in which 
 maximum 
 morbidity-rate 
 obtains. 
 
 Months in 24 
 years in which 
 minimum 
 morbidity-rate 
 obtains. 
 
 No. 
 
 Percentage 
 to total years. 
 
 No. 
 
 Percentage 
 to total years. 
 
 No. 
 
 Percentage 
 to total years. 
 
 No. 
 
 Percentage 
 to total years. 
 
 Jan. 
 
 9 
 
 26 
 
 • • • 
 
 
 9 
 
 38 
 
 • • • 
 
 • • • 
 
 Feb. 
 
 4 
 
 12 
 
 2 
 
 6 
 
 4 
 
 17 
 
 1 
 
 4 
 
 Mar. 
 
 2 
 
 6 
 
 4 
 
 12 
 
 1 
 
 4 
 
 • • • 
 
 • • • 
 
 Apr. 
 
 1 
 
 3 
 
 2 
 
 6 
 
 4 
 
 17 
 
 • • • 
 
 • • • 
 
 May . 
 
 • • • 
 
 • • • 
 
 • • • 
 
 • • • 
 
 • • • 
 
 • • • 
 
 • • • 
 
 • • • 
 
 June . 
 
 3 
 
 9 
 
 1 
 
 3 
 
 • • • 
 
 • • • 
 
 1 
 
 4 
 
 J uly . 
 
 • • • 
 
 • • • 
 
 3 
 
 9 
 
 • • • 
 
 • • • 
 
 8 
 
 33 
 
 Aug. 
 
 • • • 
 
 • • • 
 
 7 
 
 21 
 
 • • • 
 
 • • • 
 
 8 
 
 33 
 
 Sept. 
 
 1 
 
 3 
 
 5 
 
 15 
 
 1 
 
 4 
 
 5 
 
 21 
 
 Oct. 
 
 1 
 
 3 
 
 7 
 
 21 
 
 1 
 
 4 
 
 • • • 
 
 • • • 
 
 Nov. 
 
 2 
 
 6 
 
 2 
 
 6 
 
 • • • 
 
 • • • 
 
 • • • 
 
 • • • 
 
 Dec. 
 
 11 
 
 32 
 
 1 
 
 3 
 
 4 
 
 17 
 
 1 
 
 4 
 
 Total .. 
 
 34 
 
 100 
 
 34 
 
 100 
 
 24 
 
 100 
 
 24 
 
 100 
 
 and mortality usually follow each other closely, the highest mortality by no 
 means always occurred in the months of highest morbidity. 
 
 Maximum and minimum incidence of mortality and morbidity by months 
 as experienced in percentages of occurrence in series of years is shown in 
 table 52. 
 
 Maximum monthly mortality-rates occurred in percentages of the 34 years, 
 1856 to 1899, as follows: December 32, January 26, February 12, June 9, 
 March and November, each, 6, April, September, and October, each, 3. Mini¬ 
 mum monthly rates similarly expressed were distributed, August and October, 
 each, 21, September 15, March 12, July 9, February, April, and November, each, 
 6, June and December, each, 3. Maximum rates in no year fell in May, July, 
 or August, and May was the only month in which minimum rates have never 
 occurred. Somewhat different was the relation of high and low morbidity 
 occurrence in relation to months for the 24 years from 1897 to 1920. 
 
FEBRILE DISEASES 
 
 313 
 
 The percentage of occurrence of maximum morbidity-rates by months was: 
 January 38, February, April, and December, each, 17, and March, September, 
 and October, each, 4. For minimum morbidity-rates, the percentage of occur¬ 
 rence by months was: July and August, each, 33, September 21, February, 
 June, and December, each, 4. The highest monthly annual morbidity-rates 
 never occurred in May, June, July, August, or November, and similarly the 
 lowest rates were never met with in January, March, April, May, October, or 
 November. 
 
 As after 1899, in many years, there were often no deaths in two or more 
 months, it is not possible to compare the distribution of maximum and mini¬ 
 mum monthly annual mortality- and morbidity-rates for the same series of * 
 years. As the effect of season upon mortality may, of course, depend upon other 
 factors besides incidence of the disease, direct comparison of the results obtained 
 in these two different series of years is not allowable. However, it is evident 
 that, on the whole, since 1856 maximum morbidity and mortality of scarlet 
 fever must have fallen in winter and spring and minimum morbidity and 
 mortality in the summer and fall months. 
 
 While, unfortunately, they are incomplete in many important details, the data 
 presented in the foregoing pages furnish materials of exceptional value for 
 the elucidation of the natural history of scarlet fever over a period of 110 years. 
 The more salient features of this history may be summarized as follows: It has 
 not only been responsible for more deaths than any other member of this group, 
 but it has been one of the most important single causes of mortality. It was only 
 after repeated epidemic invasions that the disease became endemically estab¬ 
 lished. From a disease of slight incidence and probably mild fatality in the 
 earlier years of the nineteenth century, there was a gradual increase in mor¬ 
 tality-rates to a high peak about 1860. Without the interpolation of restrictive 
 measures in any form, there was a marked decline of mortality between 1860 
 and 1870. The mortality-rates ascended to a second high peak in 1880, and, 
 again in the complete absence of restrictive measures, declined abruptly during 
 the next 10 years, and gradually thereafter to a very low level by 1900. There 
 was a continued, though relatively slight, decline in the mortality-rates during 
 the next 20 years, in association with the use of restrictive measures. 
 
 But a hundred years of laissez faire had witnessed the ascent of this disease 
 from a comparatively innocuous to one of the most fatal of affections, followed 
 by a descent to a mortality-rate of almost negligible importance. 
 
 During the last 20 and probably the last 40.years, the morbidity-rates have 
 increased as the mortality-rates have declined; in other words, the capacity of 
 scarlet fever to attack the population has increased as its lethal force has dimin¬ 
 ished. During its state of endemicity, the tendency to periodic epidemic 
 outbreaks has persisted. 
 
 During the past 65 years, very much the same seasonal incidence has been 
 preserved. A very remarkable change has occurred in the ratio of mortality 
 among negroes as compared with whites. In 1850 the mortality-rate for the 
 former was only about one-fourth less than that for the latter, while during 
 the past 15 years, the mortality was nearly three times greater among whites 
 than among negroes. 
 
314 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 Finally, in the 20 years of their trial, administrative measures directed to 
 control the spread of scarlet fever have not been attended by any discernible 
 positive influence upon morbidity. 
 
 MEASLES. 
 
 The date of the first appearance of measles in Baltimore is not recorded, and 
 no direct references to its presence occurred before 1802. The inference that 
 it was an epidemic visitant and not endemic in Baltimore Town in the eight¬ 
 eenth century is justified by certain statements of Nathaniel Potter (60) in 
 a paper on the measles epidemics of 1802 and 1808. From Potter’s statements 
 it is clear that the disease appeared only in epidemic form in the first decade 
 of the nineteenth century, and the figures in the tables of interments show that, 
 so far as can be judged by recorded fatalities, this disease was not established 
 endemically until about 1820. Eeferring in his paper to certain deviations 
 noted in the characteristics of the disease in 1802 from the usual course of 
 “ morbillous fever,” he stated, “ as this epidemic disease observes nearly equi¬ 
 distant periods of visitation, appearing about once in 6 years, no occasion for 
 further observation presented itself till 1808.” The epidemic of the latter year, 
 according to Potter, followed the spread of the disease across the counties of 
 Maryland from Kent and Sussex Counties, Delaware, where it was recognized 
 early in January 1808. By the middle of February the disease had invaded 
 Caroline County, the eastern boundary of Maryland, and before the middle of 
 April the whole peninsula was affected. It reached Baltimore the middle of 
 May and continued to prevail until the middle of June, when apparently it 
 died out completely. 
 
 As the disease had been present in Baltimore in 1802, Potter surmised that 
 it could not now become generally epidemic and that the children born since 
 the last epidemic would be the chief sufferers. On the contrary, this was not 
 the case; usually only the older children and often only one in a family of 
 children, who had not been previously exposed, contracted the disease. Many 
 adults who escaped in 1802 were affected and suffered much more severely than 
 children. In the epidemic of 1808 the disease departed from the usual inflam¬ 
 matory type, with coryza, conjunctivitis, sore throat, pains in the back and 
 limbs, and pulmonary complications so characteristic, but was marked, almost 
 invariably, by a “ typhoid state ” in which the patient lay in a dull stupor, 
 insensible to every passing event, unless the eyes were affected. The period of 
 fever and the time of the appearance of the eruption were very irregular. Some 
 patients had a continued fever for 10 or even 15 days and no eruption. In some, 
 the eruption appeared on the third or fourth day and in others not until the 
 seventh, tenth, eleventh, thirteenth, or even the fifteenth day. Some individuals, 
 after convalescing from an attack of continuous fever without eruption, were 
 taken sick again after 20 days and had copious eruption. Two persons in the 
 same house were seldom attacked simultaneously, but the second case generally 
 took sick on the twentieth or twenty-first day from the indisposition of the first. 
 Common complications were hemorrhage from the nose, occurring either before 
 the onset of the fever or at a time of the eruption, and severe inflammation of 
 the cornea or even the whole eye. 
 
 It may be said that measles in Baltimore in the first 20 years of the nine¬ 
 teenth century behaved as it now does in village and rural communities, i. e., 
 
FEBRILE DISEASES 
 
 315 
 
 as short-lived epidemics of greater or less severity, followed by periods in which 
 the disease, in recognized form at least, entirely disappears. However, the 
 epidemic of 1808 may have marked the period of the permanent residence of 
 the disease in the city, for the absence for the records of deaths ascribed to it 
 in 1811, 1812, 1814, 1817, 1818, and 1820 does not absolutely preclude its 
 presence during those years, and the considerable death-rates of 1813 and 1810 
 may mark only exacerbations of endemic measles and not necessarily an epi¬ 
 demic due to a new importation of the disease. Much more likely, however, 
 the disease died out completely in 1808, and a new epidemic invasion began 
 5 years later, in 1813, probably in connection with the mobilization of troops 
 to defend the city, and after this date measles settled permanently in the city. 
 
 However this may be, after the outbreak of considerable severity in 1813 
 (table 34, graph 13) and that of moderate severity in 1815-1816, there came 
 the much more fatal one of 1819, which was preceded by 2 years and followed 
 by 1 year with no recorded fatalities. With slight fatalities in the next 2 years 
 (1821 and 1822), the city experienced the most fatal measles epidemic of any 
 single year of its history with a mortality-rate of 268, one that was preceded 
 by 2 years of low rates and succeeded by 5 years of descending rates. This 
 irregularity in the annual mortality rates is a characteristic retained through¬ 
 out its subsequent history in Baltimore. Its course is marked by a series of 
 peaks separated in no regular order by periods of 2, 3, 4, or even 5 years. Years 
 of exceptionally high rates were as follows: 1819, 209; 1823, 268; 1837, 129; 
 1852, 181; 1857, 103; 1869, 85. Years of moderately high rates were: 1829, 
 56; 1834, 78; 1842, 80; 1846, 78; 1854, 54; 1862, 68; 1864, 60; 1868, 75; 
 1869, 85; 1884, 62; 1886, 53; 1890, 57. Since 1893, the rate has never been 
 above 20. But though the rates have fallen so conspicuously since 1890, the 
 tendency of the annual rates to describe wide fluctuations has never been wholly 
 lost. 
 
 The curve of the annual rates averaged for 5-year periods (table 43, graph 
 14) describes a remarkable and, in some ways, characteristic course. Whether 
 the level of mortality be high or low, the curve is marked by a succession of 
 peaks and depressions, which recur with unfailing regularity. Beginning with 
 a rate of 24 for the 5-year period ending in 1815, the rate rose to 45 in 1816- 
 1820 and to 62 in 1821-1825 and fell sharply to 14 in 1826-1830. Reacting 
 in 1831-1835 to 25 and in 1836-1840 to 42, the rate fell to 21 in 1844-1845. 
 The rate then rose to 31 in 1846-1850 and to 53 in 1851-1855, fell to 41 in 
 1856-1860 and to 29 in 1861-1865. For the next 5-year period the rise was 
 sharp to 44, and the succeeding fall was gradual to 30 in 1871-1875 and to 
 15 in 1876-1880. The rate now stood at the level of 50 years before. This 
 gain was not permanent, however, for the rate rose to 29 in 1881-1885 and to 
 35 in 1886-1890. Falling to 11 in 1891-1895 and to 5 in 1896-1900, instead 
 of following its usual course, it fluctuated between 6 to 8 during the next 20 
 years. 
 
 In the rates averaged for 10-year periods (table 43, graph 15), the rate rose 
 from 35 in 1812-1820 to 38 in 1821-1830 and then fell to 33 in 1831-1840 
 and to 26 in 1841-1850. Rising again to 47 in 1851-1860, it fell to 36 in 1861- 
 1870 and to 22 in 1871-1880. Reacting to 32 in 1881-1890, the rate fell 
 sharply to 8 in 1891-1900, and but slightly to 7 in 1901-1910. During the 
 last 10 years it remained stationary. 
 
 21 
 
316 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 It is clear, therefore, from an analysis of the course of the mortality-rates, 
 that the lethal force of measles has experienced very considerable modifications 
 during the 108 years under review. After increasing very considerably between 
 1812 and 1825, it diminished during the next 10 or 15 years and then with 
 renewed vigor rose to a still higher level between 1850 and 1860. Then after a 
 period of gradual decline covering about 20 years, between 1880 and 1890, for 
 a third time it regained strength. This final effort was short-lived and rela¬ 
 tively weak, and by 1895 the lethal force of this disease had become compara¬ 
 tively impotent. During the past 25 years the mortality-rate has tended to 
 stabilize around an unprecedently low level. It will be shown later that in 
 the decennial years 1910 and 1920 nearly the whole of the mortality from 
 measles was confined to the first decade of life. Assuming, as is probably not 
 far from actual occurrence, that this held constantly, rates calculated for the 
 census years 1830 to 1920, inclusive, on the basis of the populations under the 
 tenth year of life, and thus corrected in large measure for changes in the age 
 distribution of the population, should give a much more accurate picture of the 
 changes in the lethal force of the disease. Rates specific for age so calculated 
 are given in table 44. From these it appears that the course of mortality of 
 measles in this period was characterized by four distinct waves, with the peaks 
 of the third and fourth much lower than that of the second, which was in turn 
 considerably higher than the highest level of the first. It is clear that mortality 
 attained its highest level about 1870, and that since that date it has declined 
 sharply, though in irregular fashion, to a comparatively low point. 
 
 Data for morbidity are available by months and years since 1897. While 
 case reporting has never been complete, the figures since 1900 are fairly repre¬ 
 sentative. The considerable increase in morbidity-rates since 1905 (table 53), 
 probably represents an actual increase in prevalence. The annual morbidity- 
 rates, like those for mortality during this period, are marked either by alternate 
 years of high and low levels or by comparatively high rates for 2 or 3 years 
 in series. 
 
 The annual rates for morbidity and mortality as a rule rise and fall, at 
 least in the same direction, though by no means always in proportion, for a 
 heavy case incidence is not by any means always associated with a correspond- 
 ingly great increase in the number of deaths. 
 
 The case-fatality, then, it will be observed may be higher or lower than the 
 average with either a high or low morbidity-rate. The case-fatality rate varied 
 from 0.63 per cent to 3.38 per cent. 
 
 From the monthly annual morbidity- and mortality-rates (tables 53 and 
 54), it is seen that, with few exceptions, the incidence and mortality of measles 
 have been lowest in July, August, September, October, and November, and 
 highest in December, January, February, March, April, May, and June. This 
 characteristic distribution of the disease has held in years of both high and 
 low incidence. 
 
 The influence of season upon the morbidity and mortality as expressed in the 
 months in which maximum and minimum monthly annual morbidity-rates 
 fell, from 1897 to 1920, and in which maximum mortality-rates occurred from 
 1856 to 1920, is shown in table 55. Maximum morbidity-rates occurred in 
 percentages of the total of 24 years, as follows: May 33, April 25, December 21, 
 
Table 53 .—Morbidity by months and years and monthly annual and annual rates of morbidity, per 100,000 living inhabitants, from measles, 
 
 from 1897 to 1920, inclusive. 
 
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 r'N0310©IONNH0410C5HN1010N004^00rH004 
 H04O00©'tl0C0Oi‘0<O04aiNNN^N04C0'<J(MttN 
 041—10 t- rH 04 © r-( CO -«S4 rfi t'- O- 
 
 i—I 04 t—( 
 
 NIOffiNOOIOMM'fTllffltJItOON^O 
 05-t*(C00404C0h^04^hO 00 00 C0C004M1 
 rfl 04 04 i—I 04 Tfl 04 
 
 o o O to H 
 CO 04 00 40 OO 
 
 co ■<* 
 
 t^OOOOH(NCOMl»0©NOOO)OHNCOTj(40©frOOOO 
 ©©©©©©©©©©©©©rHi—li—IrHi—IrHrHi—IrHrHOt 
 QOOOOOOOOOOOOOtOOOOOOOOOOOOO 
 
 ._, _, _ _J r—< r—I ._. ._. _ _I _ r—. ._I ._, __ _—| —< -—i , I - -< __ (—< 
 
 (317) 
 
Table 54 .—Number of deaths by months and years and monthly annual and annual rates of death, per 100,000 living inhabitants, from measles, 
 
 from 1856 to 1920, inclusive. 
 
 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 Total. 
 
 (A 
 
 Tj(MC5NHlOOOt*OU5NM10lOMOO!OHlO>ON««^NOO 
 O H (M IO CO CO T* NOOHTHIQHCO r-H <M CO 
 
 H 
 
 ft 
 
 OOOCSC'OHTjiNCOHIOMCONIOHHOCOlOCOHHMlNlOHO 
 OCClOOHOHrfHO 0««HCO'<#0)HHIOHT)(Ht't'CO 
 
 <M i—l i—1 f —1 r-l r—1 M i—1 rH i —1 i-H 
 
 6 
 
 <v 
 
 (A 
 
 • (N (N CO *Of-H • O O IO '(NOiOJOJ WOOO • Tti Hi • • • • rH 
 
 • i-H i-H 04 • r-H 04 • 04 i-H • CO 00 rH C4 • CO • • • • C4 
 
 • • • • CO • • • • • fH 
 
 a 
 
 • N a ^ • CO *1H NH • O (N N H CO (N «5 • © rH • • ♦ *<Mr- 
 
 • • • • QO C4 • • • • • CO 
 
 Nov. 
 
 « 
 
 • i-H CO rH rH i-H • O • • • CO • CO Tti CO Tti O • Tji ^ • • • • t"”* t v ** 
 
 • CO rH rH rH rH • • • • 04 • rH rH C4 • • • • • 04 
 
 • • • • • rH * * • • « • 
 
 ft 
 
 • IO 1-1 M M N • r-H . . • r- • CO N W H ICJ • 1 —(i-H • • • • IN » 
 
 • • • • • (J4 • rH • • • • • 
 
 • ••••• • •••• 
 
 Oct. 
 
 (A 
 
 • O CO N -COO • • • IO • H ^ N »0 C4 O 00 • • T*i • N • • • O 
 
 • rH • rH rH • • • • IO H 04 H 04 •• • • • • rH 
 
 • • •••• •••••• 
 
 ft 
 
 • 1—i I-H CO • CO OS • • -r-H • (N H Tjt CO M ifj (N • • I-H • CN • • -CO 
 
 • • • • • • rH • • • • • • 
 
 • • •••• •••••• 
 
 Sept. 
 
 (A 
 
 CO 00 04 CD N *04 100 • O O CD 00 H ^ CO Hi • 00 • Tti Tti Tti CO I s - 
 
 rH rH rH • CO rH • rH IO rH CO CO rH 04 • ♦ rH 04 
 
 • • • • 
 
 Q 
 
 HCOO4HC0 • CO H 04 *O4HO4TjiHTti00C0CO • H 04 • H H ^ H 00 
 
 • • r-H rH • • 
 
 ti 
 
 3 
 
 H 
 
 <A 
 
 CO 1—1 N O O • lOION^lOCO-^N^^COOO • ♦ • H N rH CO O 
 
 OHifliH .tH .(M ICO rH -*( r-H 05 N H ...rH H N CO 
 
 r-i • • r-H • • • 
 
 ft 
 
 HNCO O 05 • O* *^HO4C0O4C0HC0HCO^O4 • • • CO 04 Tti !>• 04 
 
 rH r-H • • rH CO 04 • • • rH 
 
 July. 
 
 (A 
 
 COOCDGOlOlOrtilOlO^OHlOC^^^OO^COTji • CO • 04 rH CO O IO 
 rHCO^COIO O) IO rH CO t- 00 04 04 CO *04 • CO 04 Tfi CO N 
 
 rH • • 
 
 Q 
 
 COIOOOO)OHOOHHCOTtiHCOHHC5NCOG5H • !>• • O CO T*i 00 CO 
 
 rH r-H rH rH CO rH rH • • rH r-H 0*4 
 
 • • 
 
 June. 
 
 « 
 
 COOOOOOCO • CO iCOlOOOlOt^NTUMr-lffir-100 .|>.Tt<0iTtlC005'^ 
 
 t— CO « CO • O -HH00 Tt* CO HlMINOM • <M rtf »0 CO 
 
 rH rH • rH • rH • 
 
 Q 
 
 HOlQOrH .05 i(NMa)rtOOOrtM»ONlON • N H 00 H « N OJ 
 CO r—1 04 • i—I'M rH i-H l—( • l-H i-H i-H 
 
 May. 
 
 
 CO 00 CO N TH iOJIOtH . r-H *NNON>0 •CO'!H^'<HHOOCOIONO 
 O <M r-H © • 00 H N *00 • (N lo CO H .CO tH H H CO IO <M 
 
 CO i-H • i-H • • • 
 
 Q. 
 
 H 04 Tji CO O •t'-C0*O • 1>- • CO CO £"» Tti rH . 0 H H 04 CO ID H IO N CO 
 
 IO rH • rH CO • r-H • rH rH • r-H rH 04 rH 
 
 Apr. 
 
 P3 
 
 OONOrU -CO •© • t* • • © • • t'- rfl IO •'tf • ^ t-O .»0©t— 
 
 t^-1-HC^t— • CO • 05 • tH * .IO • •© Tfl • t* <M » CO H H 
 
 <M • » i-H * • • • • i-H • i-H • 
 
 Q 
 
 rH Tti 04 IO CO • CO • • O • • rH • .ICrHrHrH • t*- 04 t"- • O CO ID 
 
 T^i r-H • rH • CO • • • rH • • 04 rH • CO • rH 
 
 Mar. 
 
 P3 
 
 • NNoot- •i-hi-ht^ • co • io t" • • •©ooi-HCC©t^co 
 
 • N H N N • CO to © • CO • © i-H • CO (M • • !>• i-H rH i-H i-H 
 
 • r-H • rH • • r-H • • • r-^ 
 
 ft 
 
 •OC4IDTti *10005 • r— • H Tti Tti • H IO 04 • • 0 ID CO H CO 04 ^ 
 
 • 04 rH • 04 rH rH • • Tti • 04 rH • • Tti 
 
 Feb. 
 
 (A 
 
 • © (N CD ^ ® 00 IfJ • • • CO ffl CD CO CD 00 O -<M • t- r~ 
 
 • CO <M • © . • • r-H M r* i-H <M ©‘I-H. 
 
 • • r-H ... CO rH • • 
 
 ft 
 
 • 04 ID H H •OOrHlOrH • • *TtilO0404CCC0H 04 04 • CO • H 04 04 
 
 • rH • rH • • • CO CO 04 • • 
 
 Jan. 
 
 P3 
 
 ■ o co •©i-HTjtiototo©© •cocooocooooooococo •tr- • co •© 
 
 • CO N • CO H 05 r-H r-H -COIN t^(M to • . ri-H 
 
 . . • CO l-H ... 
 
 ft 
 
 • O Tti • rH 04 CO rH CO r-H Tti 04 • 0 C 04 04 N 04 04 04 ID *04 • rH • CO 
 
 • • rH rH • t''» rH • • • 
 
 • • • • • • 
 
 Year. 
 
 i 
 
 • ••*••••••••••••• • •••••• • 
 
 • ••••••••••••»•#•••••••••••• 
 
 • •*••••••••••••••••••••••••• 
 
 • ••••••••••••••••••••••••••• 
 
 • ••••••*•••••••••••••••••••• 
 
 • •••••••••••••••••••••••••»• 
 
 • ••••••••••■••••••••••••••A* 
 
 • ••••••••••••••••*•••••••••• 
 
 • ••••••••••••••••••••••••••a 
 
 • •••••••••••••••••••••••*••• 
 
 CDNOO©OHiMCO^>nCOh-OOai©'-<lNCO^lDCONOOCi©H«CO 
 
 iotoioio©co©co©©co©©cof~t-~r^t^r~i>'ir^r~-r^t^oooocooo 
 
 OOOOOOOOOOCOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO 
 
 i-H i-H r-H rH r-H rH 1— H r-H I— H r-H r-H i— H i— H r-H 1— H r-H i— H r-H i-H — H r-H rH I— H i-H i-H rH rH 1—H 
 
1884 .I 50.160 1 3911391 58 1186 1 33 1109 1 34 1109 1 5 I 17 | 6 19 | ... I ... I ... I ... I ... I ... | II 3| 2 I 6 228 
 
 FEBRILE DISEASES 
 
 319 
 
 CD 50 05 50 05 I—I r-l ^ rH i—5 »—I rH 05 .-H 
 
 C4 
 
 CO 
 
 Tf5 CO Tf5 
 
 o 
 
 00 
 
 co 
 
 O C5 
 
 co 
 
 00 
 
 t— CO 
 
 00 
 
 50 
 
 T* 
 
 CO 
 
 rH 
 
 
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 05 
 
 t— 
 
 50 
 
 00 
 
 CO 
 
 
 
 rH 
 
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 05 
 
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 50 
 
 
 
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 • 
 
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 05 
 
 
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 T* 
 
 
 
 rH 
 
 • 
 
 
 >50 
 
 • 
 
 50 
 
 50 
 
 • 
 
 • 
 
 • 
 
 
 • 
 
 04 
 
 05 
 
 • 
 
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 04 
 
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 9 
 
 
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 rH 
 
 
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 • 
 
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 05 
 
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 • 
 
 04 
 
 04 
 
 • 
 
 
 • 
 
 
 05 
 
 
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 05 
 
 04 
 
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 • 
 
 
 05 
 
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 o- 
 
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 05 
 
 
 r- 
 
 • 
 
 04 
 
 
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 05 
 
 
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 05 
 
 
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 • 
 
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 • 
 
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 CO 
 
 • 
 
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 50 
 
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 rH 
 
 05 
 
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 04 
 
 50 
 
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 rH 
 
 
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 oo co 
 
 
 05 
 
 05 
 
 05 
 
 04 
 
 
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 oo 
 
 
 05 
 
 rH 
 
 04 
 
 • 
 
 
 05 
 
 05 
 
 CO 
 
 05 
 
 CO 
 
 
 04 
 
 05 
 
 T* 
 
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 rH 
 
 
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 rH 
 
 • 
 
 
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 rH 
 
 
 
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 rH 
 
 
 
 
 
 
 
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 rH 
 
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 rH 
 
 rH 
 
 50 
 
 • 
 
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 00 
 
 co 
 
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 50 
 
 rH 
 
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 00 
 
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 04 
 
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 • 
 
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 05 
 
 
 CD 
 
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 05 
 
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 T* 
 
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 05 
 
 03 
 
 04 
 
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 05 
 
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 • 
 
 
 
 04 
 
 05 
 
 r}H 
 
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 50 
 
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 05 
 
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 50 
 
 
 
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 05 
 
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 04 
 
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 05 
 
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 1 
 
 3 
 
 9 
 
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 04 
 
 05 
 
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 • 
 
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 • 
 
 05 
 
 
 
 
 
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 05 
 
 9 
 
 rH 
 
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 50 CO 
 
 50 
 
 04 
 
 T* 
 
 
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 05 
 
 
 t" 05 
 
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 rH 
 
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 • 
 
 
 
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 50 t- 
 
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 rH 
 
 
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 rH 
 
 
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 05 
 
 
 
 rH 
 
 CO 
 
 
 
 • 
 
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 1-5 CO 
 
 
 
 rH 
 
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 05 
 
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 rH 
 
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 50 
 
 Tt< 
 
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 • 
 
 2 
 
 7 
 
 00 
 
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 CO 
 
 
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 • 
 
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 50 50 05 
 
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 05 
 
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 05 
 
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 05 
 
 
 
 
 
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 05 
 
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 05 
 
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 N 
 
 • 
 
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 04 
 
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 04 
 
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 05 
 
 tH 
 
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 rH 
 
 
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 04 
 
 
 
 
 
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 * 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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 40 
 
 04 
 
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 05 
 
 
 
 
 
 
 
 
 
 
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 40 
 
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 04 
 
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 7 
 
 
 
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 5 
 
 6 
 
 05 
 
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 00 
 
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 05 CO 
 
 
 
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 rH 
 
 05 
 
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 05 
 
 eo 
 
 
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320 
 
 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 March 13, January 8. The months of occurrence of minimum rates similarly 
 expressed stood in order as follows: September 38, October 29, August 17, 
 January 13, November 4. It is very clear that conditions which obtain in Sep¬ 
 tember, October, August, January, and November, in the order named, are least 
 favorable, and those which obtain in May, April, December, and March are 
 most favorable to the incidence of this disease. It will be observed that the 
 maximum and minimum rates not infrequently fell in January. The highest 
 incidence in no year fell in February, June, or July. The percentage of months 
 in the 65 years in which the maximum mortality occurred were June 15, April 
 and July 14, March 11, January, December, and May 9, February 8, August 6, 
 and October 5. In no year was September or November the month of maximum 
 mortality. 
 
 Table 55. —Maximum incidence of mortality and maximum and minimum incidence of 
 morbidity from measles by months, from 1856 to 1920, inclusive, and 1897 and 
 1920, inclusive, respectively, and the percentage of each to the total number of 
 
 years. 
 
 Months. 
 
 Months in 65 years in 
 which maximum 
 mortality-rate obtains. 
 
 Months in 24 years in 
 which maximum 
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 Months in 24 years in 
 which minimum 
 morbidity-rate obtains. 
 
 No. 
 
 Per cent to 
 total years. 
 
 No. 
 
 Per cent to 
 total years. 
 
 No. 
 
 Per cent to 
 total years. 
 
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 6 
 
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 2 
 
 8 
 
 3 
 
 13 
 
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 5 
 
 8 
 
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 7 
 
 11 
 
 3 
 
 13 
 
 
 
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 14 
 
 6 
 
 25 
 
 
 
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 6 
 
 9 
 
 8 
 
 33 
 
 
 
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 15 
 
 
 
 
 
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 6 
 
 
 
 4 
 
 17 
 
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 5 
 
 
 
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 29 
 
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 4 
 
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 6 
 
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 5 
 
 21 
 
 • • . 
 
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 Total . 
 
 65 
 
 100 
 
 24 
 
 100 
 
 24 
 
 100 
 
 When the courses of the monthly annual morbidity- and mortality-rates from 
 1897 to 1920 (tables 53 and 54) are compared, it is noted that while, in general, 
 the mortality-rates rise and fall very closely with the morbidity-rates, this 
 is by no means always the case. 
 
 The shape of the curve of the monthly annual morbidity-rates varies greatly 
 from year to year. A rise beginning from a low point in September or October 
 may proceed gradually and smoothly, uninterruptedly or sharply and smoothly, 
 to a peak in the winter or spring. The peak may be sharp or flat. The descent 
 in the curve may be sharp or gradual. The low point reached in the different 
 years often varies within comparatively wide limits. 
 
 The influence of color, age, and sex on the incidence of measles can not be 
 determined from the records of reported cases before 1921. 
 
 Fates specific for these attributes for this year are given in table 51. It will 
 be observed that while the great majority of reported cases, 2,052 out of a 
 total of 2,236, were in individuals under the tenth year, 141 were in the second 
 
FEBRILE DISEASES 
 
 321 
 
 decade and the remainder were between the twentieth and fifty-ninth year 
 of life. Whether comparison be made in the rates for all ages or for the separate 
 age-groups, the attack-rate is seen to be much greater in whites than in negroes. 
 For the age-groups 0 to 9 years it was greater by 425 per cent. In this year 
 all of the 27 deaths ascribed to measles were in this group and the mortality- 
 rates for whites and for negroes were 21 and 12, respectively, or 75 per cent 
 higher in the latter than in the former. The case-fatality rate was 200 per 
 cent higher in negroes, 3.6 as opposed to 1.4 per cent. It would appear, then, 
 that either case reporting was much less complete among negroes or with a 
 much lower incidence rate than the white, the negro, when he does develop the 
 disease, resists it and its lethal complications much less well. In both races 
 and sexes the morbidity was considerably higher in the second than in the first 
 5 years of life; as between the sexes the rates were, on the whole, higher in 
 males than among females in whites and among females than among males 
 in negroes. 
 
 Of the 628 deaths credited to the disease during the 15-year period 1905- 
 1919 (table 46), 497 were in whites and 131 in negroes, or in a ratio of 
 approximately 4 to 1, while the proportion of white to negroes averaged 5.42 
 to 1; from which it appears that measles in Baltimore is somewhat more fatal 
 in the former than in the latter race. Among the whites the deaths were 263 in 
 males as compared with 234 in females, while among the negroes there were 67 
 deaths in males to 62 in females, indicating a higher mortality in males than in 
 females in both races, with no great difference in the proportions of the number 
 of deaths of males and females in the two races. 
 
 The distribution of the deaths from measles for age by sex and color, as of 
 1910 (table 47), based on numbers too small to warrant generalizations, shows 
 even higher mortality-rate for males than females. From table 48 in which 
 rates specific for these categories are given for 1920, and which are based on 
 larger figures than those for 1910, it will be noted that, as in the latter year, 
 the deaths were confined to the first decade and that nearly the whole mortality 
 occurred in the first five years of life. Whereas in 1920 in the various age- 
 groups in which deaths were recorded there was considerable variation in the 
 rates for the two races and sexes, the mortality for the first decade of life as a 
 whole varied but slightly for these several categories. 
 
 This remarkably interesting disease, having often invaded Baltimore in 
 the form of sharply marked epidemics, which after running a short course 
 apparently died out, became endemically established as a permanent resident 
 about 1819. Since that date it has run a definite endemic course, broken from 
 time to time by superimposed severer outbreaks, and finally, after about 90 
 years, has reached an average low rate of mortality which has become stabilized 
 since 1900. That this course has been determined by the interaction of the 
 disease upon the population and not by interferences directed to this end by 
 the activities of the health department is clear from the facts that the fall in 
 the mortality-rates was substantial long before the disease was made reportable 
 by a law (1894) which has never been complied with with any completeness, 
 that it was not until well after 1910 that the health department made any 
 serious attempt to restrict its spread by isolation, and that all the evidence at 
 hand indicates that such efforts as have been made to this end have been on the 
 
322 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 whole barren of results. If morbidity-rates during the last 20 years prove 
 anything, it is that the incidence has increased, while the case-fatality rate 
 on the whole has fallen. 
 
 INFLUENZA. 
 
 Epidemics of influenza are said by Quinan to have occurred in Baltimore 
 in 1789 and in 1807, but there have been preserved no definite records of 
 their duration or extent in morbidity and fatality. In the former year the 
 disease was popularly called "putrid cold.” Influenza (table 34, graph 11) 
 was credited in the table of interments with 25 deaths in 1815, a death-rate of 
 53, and again in 1818 with 2 deaths. This disease is not mentioned again until 
 1831 and 1832, when there occurred a severe epidemic, beginning in December 
 and lasting through April, causing 11 deaths in the former and 114 deaths in 
 the latter year, with death-rates of 12 and 124, respectively. A few deaths are 
 recorded from the disease again in 1834, 1835, 1843, 1845, 1849, and 1850 
 (with death-rates of 9, 13, 7, 1, 3, and 1, respectively), and then, with the 
 exception of a single death in each of the years 1879 and 1881, it disappeared 
 completely as a recorded cause of death until 1890. 
 
 Whether or not the disease died out completely between 1835 and 1843 or 
 remained as an endemic affection is not known. Medical men living 15 years 
 ago recalled with distinctness the outbreak of 1849 as widely diffused in the 
 population and as more fatal than is suggested by the number of deaths ascribed 
 to it in the statistical records. 
 
 It is more than probable that in all these years the deaths ascribed to influenza 
 fell short of the true number. The disease, in definitely recognizable form at 
 least, seems to have died out completely during the 40 years beween 1851 and 
 1890, and the single deaths in 1879 and 1881 are probably to be ascribed to 
 errors in diagnosis. Certain it is that the epidemic of 1890 took all of the 
 local physicians by surprise, except the few remaining who had gone through 
 the epidemic of 1849. The disease had so entirely disappeared from local 
 medical nosology that even the name was new to the great bulk of practitioners, 
 and professors of medicine had long since omitted consideration of it in their 
 lectures. 
 
 When the disease reappeared in 1890 with a high degree of incidence and a 
 weak lethal capacity, it exhibited the characteristics of 1849, rather than those 
 of 1815 and 1831-1832. But in the succeeding years it displayed a quality 
 entirely new. Instead of dying out after a year or two, the disease persisted in 
 endemic state, and in no subsequent year did it fail to be credited with deaths. 
 Upon this endemic basis there have occurred a number of short waves of com¬ 
 paratively high mortality-rates. These waves have recurred in a rather irregu¬ 
 lar fashion and their crests have occupied usually only 1 but occasionally 2 years. 
 
 Until 1918 the annual mortality-rates were never excessive as compared 
 with those often attained by other members of the group. The highest rate, 55, 
 occurred in 1891; rates of 42, 39, 46, 25, and 31 were attained in other years. 
 The lowest annual rates were 5 in 1902 and 8 in 1913. Between 1909 and 1917, 
 inclusive, the highest recorded rate was 21. 
 
 The rate bounded to 282 in 1918, and for 1919 and 1920 the rates were 56 
 and 44, respectively. Particularly in regard to the spread of the peaks and 
 
FEBRILE DISEASES 
 
 392 
 
 depressions as related to groups of years and to the character of the fluctuations 
 in the rates, the curve of the annual rates for influenza resembles that for 
 scarlet fever more closely than that for any other member of this group. The 
 contrast between the course of the disease in its purely epidemic state and in 
 its endemic state is well brought out in the comparison between the annual 
 mortality rates as averaged for 5-year periods (table 43, graph 12). With rates 
 of 13 for 1812-1815 and of 32 for 1831-1835 and negligible rates for all the 
 intervening periods, the averaged rates were for 1891-1895, 36; 1896-1900, 21; 
 1901-1905 and 1906-1910, 17; 1911-1915, 13; and 1916-1920, 84. 
 
 The great influenza epidemic of 1918 finds no analogies in either scarlet 
 fever or measles, and the closest approach to it among other diseases of this 
 group after they had become endemic is that of small-pox in 1858. 
 
 It will be observed that, during the period of endemicity, the chief incidence 
 of the disease as expressed in deaths (table 56) is in winter and spring, and that, 
 though deaths occasionally occur in July, August, September, and October, 
 they are comparatively few in number, that deaths increase in number in 
 December, and that the greatest fatality more often falls in February than 
 in any other month. To this last point there were, however, many exceptional 
 years when the highest fatality occurred in January, March, or even April or 
 May. As pointed out above, in these respects measles and influenza behave 
 very similarly. In the 31 years, 1890 to 1920, the maximum monthly annual 
 mortality-rate, as expressed in percentages of the total number of years, 
 occurred as follows, January 29, February 32, March and April, each 13, 
 December 10, October 3. 
 
 The records contain a considerable amount of instructive information con¬ 
 cerning three of the great epidemics of influenza in Baltimore. 
 
 In 1831-1832, the weekly deaths from influenza and from all causes were 
 published in the Baltimore American and Commercial Advertiser, and from 
 this source it has been possible to construct table 57 in which the course of this 
 epidemic is well illustrated. 
 
 The epidemic began apparently about the middle of December 1831, and 
 lasted until the end of April at least. By December 31 it had spread widely, 
 though it was not very fatal, for “ many families have had six or eight sick at 
 once, yet but few of these cases have ended fatally.” The highest number of 
 deaths recorded in any one month was in January, and in any one week in that 
 ending the 17th of that month. As measured in calendar months, there was a 
 rapid rise during December and January, followed by an abrupt fall in Febru¬ 
 ary, with a slight descent from the level of the latter during March, and a 
 final decided drop during April. During the whole epidemic period about 12.8 
 per cent of the whole number of deaths was attributed to influenza. 
 
 There are no data in regard to the number of cases, but from the information 
 in hand, it seems probable that the disease was very widespread, with a rela¬ 
 tively low case fatality. 
 
 The epidemic of 1890 began about the middle of January and spread rapidly 
 through the city, affecting a very large proportion of the population; but, 
 unlike that of 1831-1832 and that of 191.8, it did not affect whole families at 
 a time. No deaths were credited to the disease during this month. The acme 
 of the epidemic was during February, when the physicians in both private 
 
Table 56. —Number of deaths by months and years and the monthly annual and annual rates of death, per 100,000 living inhabitants, from in¬ 
 fluenza, from 1890 to 1920, inclusive. 
 
 D = death. R = rate. 
 
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FEBRILE DISEASES 
 
 325 
 
 practice and in dispensaries were overburdened. The fatalities attributed to the 
 disease were only 10, a comparatively small number in comparison with the 
 large number of cases. There was, however, a decided increase in the number 
 of deaths from all causes and from pneumonia, bronchitis, and pulmonary 
 tuberculosis. As a conspicuous cause of death, influenza did not show its 
 force until 1891 and 1892. After the drop in the morbidity-rate in 1893, the 
 disease settled into an endemic state, and in lethal capacity never reached its 
 previous level until 1918. 
 
 The course of influenza during the first 8 months of 1918 was not unusual, 
 except in one feature, namely, the occurrence during February and March 
 among some men living in the eastern section of the city and working daily 
 in the government construction camps just without the city limits of a type 
 of influenza characterized by acute laryngitis, often complicated by severe 
 hemorrhage. Though the affection often attacked the household associates of 
 
 Table 57. —Number of deaths and rate of death, per 100,000 living inhabitants, from 
 influenza and all causes, by weeks, for 1831 and 1832. 
 
 D = death. R = rate. 
 
 Week 
 
 ending. 
 
 Influenza. 
 
 All causes. 
 
 Week 
 
 ending. 
 
 Influenza. 
 
 All causes. 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 1831 
 
 
 
 
 
 1832 
 
 
 
 
 
 Dec. 19... 
 
 2 
 
 117 
 
 49 
 
 2875 
 
 Feb. 
 
 21... 
 
 3 
 
 170 
 
 52 
 
 2943 
 
 Dec. 27... 
 
 9 
 
 528 
 
 57 
 
 3344 
 
 Feb. 
 
 28... 
 
 10 
 
 566 
 
 60 
 
 3396 
 
 1832 
 
 
 
 
 
 Mar. 
 
 5... 
 
 9 
 
 509 
 
 59 
 
 3339 
 
 Jan. 3... 
 
 13 
 
 736 
 
 60 
 
 3396 
 
 Mar. 
 
 12... 
 
 3 
 
 170 
 
 58 
 
 3282 
 
 J an. 10... 
 
 12 
 
 679 
 
 58 
 
 3282 
 
 Mar. 
 
 20... 
 
 8 
 
 453 
 
 60 
 
 3396 
 
 Jan. 17... 
 
 15 
 
 849 
 
 55 
 
 3113 
 
 Mar. 
 
 27... 
 
 4 
 
 226 
 
 51 
 
 2886 
 
 Jan. 24... 
 
 4 
 
 226 
 
 44 
 
 2490 
 
 Apr. 
 
 3... 
 
 5 
 
 283 
 
 48 
 
 2716 
 
 Jan. 31... 
 
 10 
 
 566 
 
 49 
 
 2773 
 
 Apr. 
 
 10... 
 
 4 
 
 226 
 
 49 
 
 2773 
 
 Feb. 7... 
 
 9 
 
 509 
 
 52 
 
 2943 
 
 Apr. 
 
 17... 
 
 • • • 
 
 • • • 
 
 43 
 
 2434 
 
 Feb. 14... 
 
 3 
 
 170 
 
 49 
 
 2773 
 
 Apr. 
 
 24... 
 
 2 
 
 113 
 
 27 
 
 1528 
 
 these men; it spread to other households but rarely. Both lobar and broncho 
 pneumonia were more prevalent than usual in the spring of 1918, and a con¬ 
 siderable proportion of the cases of pneumonia, complicating cases of measles 
 and whooping-cough during the winter and spring months, conformed to the 
 type of acute interstitial pneumonia described by MacCallum and others in 
 army camps and associated with the presence of Streptococcus hemolyticus. 
 This highly fatal type of pneumonia had become well established in the city 
 before the beginning of the great influenza-pneumonia epidemic in September. 
 During the latter part of August and early September there was a sharp out¬ 
 break of influenza among the military and labor forces in the construction 
 and other army camps to the east and southeast of the city, and during the third 
 week of September, just as in the spring, cases of the disease in very severe 
 type occurred first in the eastern section of the city among men residing there, 
 but working in the army camps, where they came into contact with the army 
 personnel. The disease spread first to the household associates of these men, 
 and then within a short time over the whole eastern section of the city. In the 
 last week of September, influenza of the same severe type appeared in the 
 
326 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 southern section of the city, bounding the west side of the basin and harbor, the 
 seat of shipyards and docks, where the inhabitants were most intimately asso¬ 
 ciated with overseas shipping. In a short time the disease spread rapidly in 
 the neighboring wards. It is clearly established that the malady first attacked, 
 in severe form, at least, those whose work brought them into association with 
 the army. The wards of the north and northwestern sections of the city were 
 invaded somewhat later. There were probably early in the epidemic a number 
 of foci in various parts of the city that did not come so sharply to the attention 
 of the health department. 
 
 Influenza was included among the reportable diseases shortly after the 
 beginning of the epidemic, and the first cases (10 in number) were reported 
 on September 26. Between this date and December 27, 21,902 cases were 
 reported, but, as it was for some weeks a physical impossibility for an over¬ 
 worked profession to report cases with any degree of completeness, it is probable 
 that but one-third of the actual number of cases was reported and that 75,000 
 would be an underestimate. From the daily record it appears that the peak of 
 the epidemic was reached about October 10, when the highest number of case 
 reports (1962) was received. By October 29 the daily number of case reports 
 had fallen to 514, and by the 31st to 90. During November the number fell to 
 a lower level. There was a distinct rise in December, which became more marked 
 at the close of the month. 
 
 The course of the disease by weeks from September 7, 1918, to April 25, 
 1919, is shown by the weekly annual rates for influenza, together with the 
 weekly annual rates for deaths from all causes, in table 58. The curves for 
 these rates, with the rapid rise to a high peak, between the week ending Sep¬ 
 tember 28, and the weeks ending October 12 and 19, for morbidity and mor¬ 
 tality respectively, and the succeeding declines, almost as sharp, reaching a 
 low point the last week in November, are distinctive and entirely unlike those 
 of previously recorded epidemics of influenza in Baltimore. The curves for 
 the ensuing winter and spring followed the usual endemic course, very much 
 as if this overwhelming outbreak of September, October, and November had 
 not occurred. This outbreak was for Baltimore exceptional in its season of 
 occurrence, the rapidity of its course, and its high fatality. The full lethal 
 force of this outbreak is reflected more completely by the rates for deaths 
 from all causes than by those for influenza alone; for by the rules of classi¬ 
 fication, while deaths of influenza and broncho-pneumonia are classified 
 under influenza, those ascribed to influenza and lobar pneumonia, of which 
 there are many, and influenza complicating such diseases as typhoid fever and 
 whooping-cough are not. Influenza was assigned also as a contributory cause 
 of death in a number of instances in connection with pulmonary tuberculosis, 
 organic diseases of the heart, and other affections. There was a large number 
 of deaths assigned to primary broncho and lobar pneumonia without influenza. 
 It is certain that in many instances the diagnosis between broncho-pneumonia 
 and lobar pneumonia complicating influenza was in error, and that many, if 
 not most, of the cases diagnosed as lobar pneumonia really belonged to the 
 former category and should in truth under the rules have been classified under 
 influenza. As a matter of fact, there is in the light of present knowledge no 
 adequate reason for this distinction. 
 
FEBRILE DISEASES 
 
 327 
 
 Neither the reported cases nor the deaths of influenza were analyzed for 
 distribution according to age. In regard to color and sex, the 81 deaths of 
 influenza occurring between January 1 and September 1 were divided as follows : 
 White, total 52, male 25, females 27; colored, total 29, male 13, female 16. 
 The differences in the number of fatalities by sex were not great, but the 
 
 Table 58 .—Number of cases arid deaths and morbidity and mortality rates, per 100,000 
 living inhabitants, from influenza and number of deaths and mortality rate from 
 all causes, by weeks, for 191S and 1919. 
 
 O = cases. R = rate. D = death. 
 
 Week ending. 
 
 Influenza. 
 
 Influenza. 
 
 All causes. 
 
 C 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 1918 
 
 
 
 
 
 
 
 Sept. 7. 
 
 • • • 
 
 • • • 
 
 1 
 
 8 
 
 184 
 
 1330 
 
 Sept. 14. 
 
 • • • 
 
 • • • 
 
 • • • 
 
 • • • 
 
 190 
 
 1374 
 
 Sept. 21. 
 
 • • • 
 
 • • • 
 
 • • • 
 
 • • • 
 
 163 
 
 1179 
 
 Sept. 28. 
 
 53 
 
 447 
 
 3 
 
 25 
 
 194 
 
 1403 
 
 Oct. 5. 
 
 3165 
 
 26718 
 
 71 
 
 599 
 
 321 
 
 2321 
 
 Oct. 12. 
 
 8945 
 
 75511 
 
 344 
 
 2904 
 
 793 
 
 5733 
 
 Oct. 19. 
 
 5416 
 
 45720 
 
 614 
 
 5183 
 
 1691 
 
 12226 
 
 Oct. 26. 
 
 2374 
 
 20041 
 
 327 
 
 2760 
 
 1358 
 
 9818 
 
 Nov. 2. 
 
 588 
 
 4964 
 
 139 
 
 1173 
 
 613 
 
 4432 
 
 Nov. 9. 
 
 75 
 
 633 
 
 39 
 
 329 
 
 314 
 
 2270 
 
 Nov. 16. 
 
 116 
 
 979 
 
 14 
 
 118 
 
 234 
 
 1692 
 
 Nov. 23. 
 
 60 
 
 507 
 
 4 
 
 34 
 
 238 
 
 1721 
 
 Nov. 30. 
 
 94 
 
 794 
 
 12 
 
 101 
 
 212 
 
 1533 
 
 Dec. 6. 
 
 164 
 
 1384 
 
 29 
 
 245 
 
 230 
 
 1663 
 
 Dec. 13. 
 
 256 
 
 2161 
 
 22 
 
 186 
 
 248 
 
 1793 
 
 Dec. 20. 
 
 324 
 
 2735 
 
 21 
 
 177 
 
 220 
 
 1591 
 
 Dec. 27. 
 
 272 
 
 2296 
 
 17 
 
 144 
 
 235 
 
 1699 
 
 1919 
 
 
 
 
 
 
 
 Jtin. 3* •••••••• t •• • • 
 
 294 
 
 2126 
 
 14 
 
 101 
 
 227 
 
 1641 
 
 Jan. 10. 
 
 402 
 
 2907 
 
 24 
 
 174 
 
 279 
 
 2017 
 
 Jan. 17. 
 
 978 
 
 7071 
 
 31 
 
 224 
 
 289 
 
 2090 
 
 Jan. 24. 
 
 1445 
 
 10447 
 
 61 
 
 441 
 
 401 
 
 2899 
 
 Jan. 31. 
 
 847 
 
 6124 
 
 53 
 
 383 
 
 362 
 
 2617 
 
 Feb. 7. 
 
 355 
 
 2567 
 
 43 
 
 311 
 
 364 
 
 2632 
 
 Feb. 14. 
 
 262 
 
 1894 
 
 42 
 
 304 
 
 313 
 
 2263 
 
 Feb. 21. 
 
 199 
 
 1439 
 
 23 
 
 166 
 
 335 
 
 2422 
 
 Feb. 28. 
 
 173 
 
 1251 
 
 22 
 
 159 
 
 272 
 
 1967 
 
 Mar. 7. 
 
 115 
 
 831 
 
 11 
 
 80 
 
 254 
 
 1836 
 
 Mar. 14. 
 
 74 
 
 535 
 
 11 
 
 80 
 
 251 
 
 1815 
 
 Mar. 21. 
 
 21 
 
 152 
 
 15 
 
 108 
 
 219 
 
 1583 
 
 Mar. 28. 
 
 21 
 
 152 
 
 10 
 
 72 
 
 212 
 
 1533 
 
 Apr. 4. 
 
 12 
 
 87 
 
 3 
 
 22 
 
 211 
 
 1526 
 
 Apr. 11. 
 
 14 
 
 101 
 
 3 
 
 22 
 
 230 
 
 1663 
 
 Apr. 18. 
 
 5 
 
 36 
 
 3 
 
 22 
 
 178 
 
 1287 
 
 Apr. 25. 
 
 4 
 
 29 
 
 4 
 
 29 
 
 233 
 
 1685 
 
 disease was much more fatal for negroes than for whites, the ratio of deaths 
 being as 5 to 3, in a population with whites in the proportion of 5.75 whites 
 to 1 negro. Of the 1,662 deaths from influenza between September 1 and 
 December 31, there were whites, total 1,403, males 693, females 710, and 
 negro, total 259, males 123, females 136. Here there were no significant 
 differences in distribution either by sex or by color. The incidence of influenza 
 
328 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 deaths in white and negro was in the proportion of about 5 to 1, in a popula¬ 
 tion racially distributed in a ratio of about 5.75 to 1. So in the period of the 
 epidemic the most usual position of whites as to fatality from influenza was 
 largely lost. This change is clearly shown in table 59. As between the sexes 
 there were no significant differences in the rates for white, but among negroes 
 the rates for males were distinctly higher than those for females. 
 
 The point has been made that the influenza epidemic of 1918 was accom¬ 
 panied by epidemic incidence of broncho-pneumonia, and that the number of 
 deaths credited to influenza fell far short of the true number, because, on 
 account of the rules of classification, deaths ascribed to this disease with lobar 
 pneumonia w T ere classified under the latter rubric. This is fully borne out by 
 table 59, in which it will be observed that during the period of the influenza 
 epidemic, the monthly annual rates for both broncho-pneumonia and lobar 
 pneumonia were not only much higher than normal, but moved synchronously 
 with those for influenza. In both cases the rates for negroes were higher than 
 those for whites, and with the exception of broncho-pneumonia in the negro, 
 in whom the reverse occurred, the recorded mortality was decidedly greater 
 among males than among females of both races. 
 
 The high fatality of the epidemic outburst was apparently due to the unusual 
 virulence of the disease itself and to the fact that it happened to occur at a 
 time when Streptococcus hemolyticus broncho-pneumonia was prevalent. 
 
 As elsewhere, the disease spread through the community like wildfire, striking 
 down whole families, sometimes all at once, and sometimes the various indi¬ 
 viduals in succession. In the height of the outbreak physicians, depleted in 
 numbers owing to the war, could not respond to all of their calls; the hospitals, 
 crippled by lack of full corps of physicians, nurses, and orderlies, were unable 
 properly to care for the crowds demanding their care, and every public and 
 private service was seriously embarrassed. 
 
 The figure cut by the health department was distressing. In the middle of 
 September, the writer, realizing, as must any one familiar with what is known 
 of the natural history of influenza in general and acquainted with its recent 
 behavior in Europe and in New England at the time, that it was hopeless to 
 expect by the use of any known methods to prevent its entrance into the city 
 or to stop its spread when it entered, advised the commissioner of health not 
 to complicate the situation by fruitless attempts at interference, but to organize 
 about the health department all the various medical, nursing, and relief 
 agencies for the care of those who must inevitably be stricken. Finally adopting 
 this view after ascertaining that it was acquiesced in by a number of leading 
 physicians whom he consulted, plans were laid to organize the social forces 
 for aid. Before anything concrete was accomplished, however, the epidemic 
 was well under way, and at the critical time, falling under the influence of the 
 remarkable circular letter of the Surgeon General of the United States Public 
 Health Service, embodying recommendations of archaic type, and bowing, in 
 the face of knowledge and common sense, to authority, the commissioner 
 spent his energies in issuing orders which, if obeyed, would have paralyzed 
 every activity necessary among the inhabitants of a great city in the midst of 
 war. So far did restrictive regulations extend that for some days it was a 
 criminal offense for a junk-dealer to sell scrap-iron. In consequence, the staff 
 of the health department devoted its energies mainly to trying to restrict 
 
FEBRILE DISEASES 
 
 329 
 
 Table 59. 
 INFLUENZA. 
 
 D = death. R = rate. 
 
 
 
 
 
 
 White. 
 
 
 
 
 
 Colored. 
 
 
 
 
 Total. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Total. 
 
 Male. 
 
 Female. 
 
 Total. 
 
 Male. 
 
 Female. 
 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 1918 
 Jan. .. 
 
 24 
 
 46 
 
 18 
 
 41 
 
 7 
 
 33 
 
 11 
 
 49 
 
 6 
 
 71 
 
 4 
 
 104 
 
 2 
 
 44 
 
 Feb. .. 
 
 14 
 
 30 
 
 10 
 
 25 
 
 6 
 
 30 
 
 4 
 
 20 
 
 4 
 
 53 
 
 3 
 
 86 
 
 1 
 
 24 
 
 Mar. .. 
 
 20 
 
 38 
 
 12 
 
 27 
 
 5 
 
 23 
 
 7 
 
 31 
 
 8 
 
 95 
 
 5 
 
 130 
 
 3 
 
 66 
 
 Apr. .. 
 
 12 
 
 24 
 
 7 
 
 16 
 
 3 
 
 14 
 
 4 
 
 19 
 
 5 
 
 61 
 
 • • • • 
 
 • • • • 
 
 5 
 
 113 
 
 May .. 
 
 6 
 
 11 
 
 4 
 
 9 
 
 3 
 
 14 
 
 1 
 
 4 
 
 2 
 
 24 
 
 1 
 
 26 
 
 1 
 
 22 
 
 June .. 
 
 2 
 
 4 
 
 1 
 
 2 
 
 1 
 
 5 
 
 • • • • 
 
 • • • • 
 
 1 
 
 12 
 
 • • • • 
 
 • • • • 
 
 1 
 
 23 
 
 July .. 
 A U£T. 
 
 1 
 
 2 
 
 
 
 
 
 
 
 1 
 
 12 
 
 
 
 1 
 
 22 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Sept. .. 
 
 11 
 
 22 
 
 10 
 
 23 
 
 5 
 
 23 
 
 5 
 
 23 
 
 1 
 
 12 
 
 1 
 
 27 
 
 • • • • 
 
 • • • • 
 
 Oct. .. 
 
 1464 
 
 2791 
 
 1245 
 
 2826 
 
 600 
 
 2750 
 
 645 
 
 2901 
 
 219 
 
 2604 
 
 102 
 
 2650 
 
 117 
 
 2566 
 
 Nov. .. 
 
 93 
 
 183 
 
 70 
 
 164 
 
 44 
 
 208 
 
 26 
 
 121 
 
 23 
 
 283 
 
 10 
 
 268 
 
 13 
 
 295 
 
 Dec. .. 
 
 94 
 
 179 
 
 78 
 
 177 
 
 44 
 
 202 
 
 34 
 
 153 
 
 16 
 
 190 
 
 10 
 
 260 
 
 6 
 
 132 
 
 Total . 
 
 1741 
 
 282 
 
 1455 
 
 281 
 
 718 
 
 279 
 
 737 
 
 282 
 
 286 
 
 289 
 
 136 
 
 300 
 
 150 
 
 279 
 
 BRONCHOPNEUMONIA. 
 
 1918 
 Jan. .. 
 
 81 
 
 154 
 
 52 
 
 118 
 
 28 
 
 128 
 
 24 
 
 108 
 
 29 
 
 345 
 
 13 
 
 338 
 
 16 
 
 351 
 
 Feb. .. 
 
 120 
 
 253 
 
 85 
 
 214 
 
 58 
 
 294 
 
 27 
 
 134 
 
 35 
 
 461 
 
 12 
 
 345 
 
 23 
 
 559 
 
 Mar. .. 
 
 85 
 
 162 
 
 56 
 
 127 
 
 31 
 
 142 
 
 25 
 
 112 
 
 29 
 
 345 
 
 18 
 
 468 
 
 11 
 
 241 
 
 Apr. .. 
 
 86 
 
 169 
 
 53 
 
 124 
 
 28 
 
 133 
 
 25 
 
 116 
 
 33 
 
 406 
 
 12 
 
 322 
 
 21 
 
 476 
 
 May .. 
 
 50 
 
 95 
 
 34 
 
 77 
 
 18 
 
 82 
 
 16 
 
 72 
 
 16 
 
 190 
 
 8 
 
 208 
 
 8 
 
 175 
 
 June .. 
 
 29 
 
 57 
 
 24 
 
 56 
 
 9 
 
 43 
 
 15 
 
 70 
 
 5 
 
 61 
 
 3 
 
 81 
 
 2 
 
 45 
 
 J uly .. 
 
 24 
 
 46 
 
 13 
 
 30 
 
 9 
 
 41 
 
 4 
 
 18 
 
 11 
 
 131 
 
 4 
 
 104 
 
 7 
 
 154 
 
 Aug. .. 
 
 11 
 
 21 
 
 5 
 
 11 
 
 3 
 
 14 
 
 2 
 
 9 
 
 6 
 
 71 
 
 1 
 
 26 
 
 5 
 
 110 
 
 Sept. .. 
 
 24 
 
 47 
 
 15 
 
 35 
 
 8 
 
 38 
 
 7 
 
 33 
 
 9 
 
 111 
 
 4 
 
 107 
 
 5 
 
 113 
 
 Oct. .. 
 
 357 
 
 681 
 
 288 
 
 654 
 
 160 
 
 733 
 
 128 
 
 576 
 
 69 
 
 821 
 
 20 
 
 520 
 
 49 
 
 1075 
 
 Nov. .. 
 
 61 
 
 120 
 
 51 
 
 120 
 
 27 
 
 128 
 
 24 
 
 112 
 
 10 
 
 123 
 
 3 
 
 81 
 
 7 
 
 159 
 
 Dec. .. 
 
 66 
 
 126 
 
 53 
 
 120 
 
 32 
 
 147 
 
 21 
 
 94 
 
 13 
 
 155 
 
 4 
 
 104 
 
 9 
 
 197 
 
 Total . 
 
 994 
 
 161 
 
 729 
 
 141 
 
 411 
 
 160 
 
 318 
 
 121 
 
 265 
 
 268 
 
 102 
 
 225 
 
 163 
 
 304 
 
 LOBAR PNEUMONIA. 
 
 1918 
 Jan. .. 
 
 129 
 
 246 
 
 90 
 
 204 
 
 53 
 
 243 
 
 37 
 
 166 
 
 39 
 
 464 
 
 24 
 
 623 
 
 15 
 
 329 
 
 Feb. .. 
 
 134 
 
 283 
 
 89 
 
 224 
 
 54 
 
 274 
 
 35 
 
 174 
 
 45 
 
 592 
 
 31 
 
 892 
 
 14 
 
 340 
 
 Mar. .. 
 
 138 
 
 263 
 
 71 
 
 161 
 
 42 
 
 192 
 
 29 
 
 130 
 
 67 
 
 797 
 
 42 
 
 1091 
 
 25 
 
 548 
 
 Apr. .. 
 
 90 
 
 177 
 
 64 
 
 150 
 
 35 
 
 166 
 
 29 
 
 135 
 
 26 
 
 320 
 
 17 
 
 456 
 
 9 
 
 204 
 
 May ..' 
 
 36 
 
 69 
 
 19 
 
 43 
 
 12 
 
 55 
 
 7 
 
 31 
 
 17 
 
 202 
 
 12 
 
 312 
 
 5 
 
 110 
 
 June .. 
 
 25 
 
 49 
 
 15 
 
 35 
 
 9 
 
 43 
 
 6 
 
 28 
 
 10 
 
 123 
 
 5 
 
 134 
 
 5 
 
 113 
 
 J uly .. 
 
 13 
 
 25 
 
 9 
 
 20 
 
 5 
 
 23 
 
 4 
 
 18 
 
 4 
 
 48 
 
 1 
 
 26 
 
 3 
 
 66 
 
 Aug. .. 
 
 12 
 
 23 
 
 6 
 
 14 
 
 4 
 
 18 
 
 2 
 
 9 
 
 6 
 
 71 
 
 2 
 
 52 
 
 4 
 
 88 
 
 Sept. .. 
 
 39 
 
 77 
 
 29 
 
 68 
 
 23 
 
 109 
 
 6 
 
 28 
 
 10 
 
 123 
 
 7 
 
 188 
 
 3 
 
 68 
 
 Oct. .. 
 
 1696 
 
 3233 
 
 1409 
 
 3198 
 
 784 
 
 3593 
 
 625 
 
 2811 
 
 287 
 
 3413 
 
 155 
 
 4026 
 
 132 
 
 2895 
 
 Nov. .. 
 
 103 
 
 203 
 
 75 
 
 176 
 
 52 
 
 246 
 
 23 
 
 107 
 
 28 
 
 344 
 
 14 
 
 376 
 
 14 
 
 317 
 
 Dec. .. 
 
 118 
 
 225 
 
 92 
 
 209 
 
 54 
 
 247 
 
 38 
 
 171 
 
 26 
 
 309 
 
 16 
 
 416 
 
 10 
 
 219 
 
 Total . 
 
 2533 
 
 410 
 
 1968 
 
 379 
 
 1127 
 
 439 
 
 841 
 
 321 
 
 565 
 
 571 
 
 326 
 
 719 
 
 239 
 
 445 
 
330 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 absolutely essential activities or in explaining to irate and embarrassed citizens 
 how and when, if at all, they could, within the regulations, sell or buy food, 
 clothing, and drugs, go to and from their work, or get married or buried. 
 Not only schools, churches, and theaters, but many businesses, were practically 
 closed. The only real service was done by the scant force of nurses in helping 
 some of the sick, by one officer in getting a sufficient number of common coffins 
 made to break the coffin monopoly, and by another in assigning laborers to 
 bury the accumulated dead at cemeteries. There was no coordination of helping 
 agencies, each of which did the best it could without special direction and 
 assistance. In the health department chaos reigned and futile conflicting 
 restrictive orders gushed forth in ever-increasing volume. 
 
 SUMMARY. 
 
 The curve for the annual mortality rates for this group of diseases as a 
 whole (table 34, graphs 11 and 13) shows not only considerable variations from 
 year to year, but a number of very distinct and usually sharply crested waves 
 which extend over periods of several years. 
 
 The wide fluctuations in the total rates are caused in part by similar changes 
 in the rates for the several members of the group and in part by the fact that 
 the various members enter at different times and some of them, after their 
 first entry, drop out for longer or shorter periods. For these reasons it is im¬ 
 practicable to represent graphically and to analyze sharply the contribution of 
 each to the whole. The peaks of the successive waves of the total annual 
 mortality rates tend to become higher up to 1872. After this date, with the 
 exception of the peak of 1883, they tend to fall in an irregular manner to much 
 lower levels until 1918, when there is a sharp reaction to a relatively high 
 level. Years with exceptionally high rates were as follows: 1823, 272; 1834 
 and 1837, each, 303; 1844, 270; 1845, 296; 1848, 314; 1852, 353; 1857, 328; 
 1858, 434; 1862, 338; 1864, 304; 1872, 473; 1883, 305; 1918, 296. The high 
 total rates of many of these peak years, as well as in other years, were often 
 due to extraordinarily high rates for a single disease. With the possible excep¬ 
 tion of small-pox and varicella, the various numbers of the group developed 
 high and low rates of mortality apparently quite independently of each other. 
 There is no striking and constant similarity in the course of their curves as 
 regards years of high and low rates. 
 
 From the total rate and the rates for the various diseases, as averaged for 
 5-year periods from 1811 to 1920 (table 43, graphs 12 and 14), a clearer idea 
 may be gotten of the death toll of the group as a whole and the relative 
 importance of the contributions of its various members. Beginning with a 
 total rate of 83 in 1812-1815, there was a drop to 48 in 1815-1820, a rise to 
 132 in 1821—1825, and a fall to 53 in 1826—1830. Influenza in the first period 
 and measles and small-pox during the whole time were the chief contributors. 
 Due very largely to scarlet fever and in some degree to influenza, the total 
 rate jumped to 202 in 1831-1835. After falling to 154 in 1836-1840, the rate 
 rose continuously to 233 in 1856-1860. During the 30 years from 1831 to 1860, 
 scarlet fever was by far the largest single contributor to the total rate; small-pox 
 played, on the whole, a less important part than measles; and influenza did 
 
FEBRILE DISEASES 
 
 331 
 
 not appear significantly after 1835. After a moderate decline to 215 in 1861- 
 1865 and influenced very largely by the falling-olf in the mortality from scarlet 
 fever, the rate fell abruptly to 107 in 1866-1870. Owing particularly to 
 decided increases in the rates for small-pox and scarlet fever, the total rate 
 reached to 248 in 1871-1875. In association with changes in the rates for small¬ 
 pox and measles, the total rate declined in 1876-1880 to 133 and in 1881-1885 
 reached 147. A remarkable fall in the total rate to 47 in 1886-1890 was brought 
 about by the final disappearance of small-pox as a serious cause of death and 
 by a distinct drop in the rate for scarlet fever. The rise of the total rate to 
 72 in 1891-1895 was due very largely to the reentrance of influenza, for the 
 rise in the rate for scarlet fever was largely offset by a fall for that of measles. 
 The descent in the total rate to 33 in 1896-1900 was associated with the 
 
 Graph 16 (from table 43). Crude mortality-rates from small-pox, varicella, 
 scarlet fever, measles, and influenza, averaged by 10-year periods, from 1812 
 to 1920, inclusive. 
 
 decline of measles and scarlet fever to new low levels and to a considerable 
 decrease in the rate for influenza. The total rate now stood at the lowest level 
 ever attained in our records. Slight changes in the rates for all three contribu¬ 
 tors carried the rate for 1901-1905 up to 37, and brought it down to 31 in 
 1906-1910 and 27 in 1911-1915. A very considerable rise in the rate for 
 influenza caused the total rate to reach 94 in 1916-1920. It will be observed 
 that for the group as a whole the rates ascended in a somewhat irregular fashion 
 until 1871-1875, and that, with this date as a turning-point, they declined 
 by irregular steps. But for the reentrance of influenza upon the scene in 1890, 
 this decline would have been much less irregular and much more marked, and 
 by 1900 the rate for the whole group would have become negligible. 
 
 The curve of the total rates as averaged for 10-year periods (table 43 and 
 graph 16) rose from 64 in 1812-1820 to the peak rate of 225 in 1851-1860. 
 
332 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 After a drop to 161 in 1861-1870, succeeded by a rise to 191 in 1871-1880, there 
 was a continuous decline to 34 in 1901-1910. This was followed by a reaction to 
 60 in 1911-1920. Thus, after 100 years, the mortality-rate for this group as a 
 whole has returned to the same level from which it started. Measles, scarlet 
 fever, and small-pox were the longest and most weighty contributors to the 
 total rate, and of these scarlet fever was by far the most important. It was 
 characterized by the highest averaged rates and determined the shape of the 
 curve of the total rate for most of the period. Measles ran, on the whole, the 
 more consistently even course. Of the three, small-pox fluctuated the most 
 widely and soonest fell in importance. Influenza contributed forcibly at the 
 beginning and end of the period, and after 1900 it determined the shape 
 of the curve. The influence of chicken-pox was comparatively negligible 
 throughout. 
 
 The percentage of the number of deaths from this group of diseases to the 
 number of deaths from all causes varied considerably at different periods. 
 Percentages as high as 11, 12, 13, 14, and 15 occurred in several years. In 
 1858, 16 per cent of all deaths were ascribed to these affections. After 1883, 
 as judged by this criterion, they sank to a relatively unimportant position. 
 During the 109 years through which their course has been traced, the members 
 of this group of diseases have disclosed very clearly and distinctly certain 
 important attributes which must be regarded as inherently characteristic of 
 their natural history in a population of the size and composition of Baltimore. 
 In the period under consideration, each except chicken-pox, which was appar¬ 
 ently already endemically established, has repeatedly entered, attacked con¬ 
 siderable numbers in the population, and then, certainly as causes of death and 
 as clinically recognizable diseases, completely disappeared, often for a con¬ 
 siderable period of years. 
 
 The disappearance of each of these diseases from the community after these 
 epidemic outbreaks has occurred in the absence of the use of any measures or 
 at least of reasonably adequate measures, designed to control their spread. 
 When in this purely epidemic phase, each of these diseases has invariably run 
 its course in from 6 to 36 months. After repeated experiences of this character, 
 small-pox, measles, scarlet fever, and influenza, each in turn and after some 
 particular epidemic invasion, have became endemically established, with cases 
 and deaths each year for a number of years in succession. Finally, after becom¬ 
 ing endemically intrenched, they have all exhibited certain common character¬ 
 istics in their succeeding course. The first of these is the persistence of the 
 epidemic qualities, as shown by exacerbations of incidence and fatality extend¬ 
 ing over several years, followed by periods of remission or depression during 
 which incidence and fatality were much reduced. These rest periods varied in 
 length for the different diseases and for the same disease at different times 
 in its history. A second characteristic is the occurrence of long undulations in 
 the morbidity and mortality curves covering periods measured by a number 
 of years. A third characteristic, shown particularly by small-pox, measles, and 
 scarlet fever, the diseases of greatest fatality longest endemically established, 
 is a gradual loss of lethal force, without, in the case of measles and scarlet fever, 
 loss of capacity to attack. Even influenza, as established endemically between 
 1891 and 1917, showed on the whole a distinct impairment in force of mor¬ 
 tality. Though deaths from varicella have always been comparatively few in 
 
FEBKILE DISEASES 
 
 333 
 
 number, the course of its mortality-rates indicates the same quality of dimin¬ 
 ishing lethal power. A fourth characteristic common to measles, scarlet fever, 
 chicken-pox, and perhaps influenza during their period of endemicity is an 
 increase in invasive capacity, or attack-rate, as they have lost in lethal force. 
 
 Among other attributes held in common, these affections have in the main the 
 same seasonal distributions. A studv of their incidence fails to disclose evidence 
 that one exerts any exclusive influence upon another. Two or more have 
 existed in intensive form in the community at the same time, and severe out¬ 
 breaks of several have occurred in the same year. 
 
 As has been brought out in consideration of each of these diseases separately, 
 the usual measures of a restrictive sort to prevent the spread of any of them 
 were not undertaken until late in this history. None of them was made report- 
 able b} r law until 1882, and none, except small-pox, was reported with any 
 reasonably accurate completeness before 1897. The usual restrictive measures, 
 including fumigation, were not begun against scarlet fever until after 1900, 
 or against measles until after 1910—in each case long after the disease had 
 ceased to be attended with high rates of mortality. Against influenza, spar¬ 
 ingly reported since the fall of 1918, no measures have been attempted. 
 Accommodations for hospitalization of more than a small percentage of patients 
 and contacts, except for small-pox since 1885, have never been available. 
 
 The conclusion is inevitable that all of these diseases have defied all the 
 restrictive measures, such as quarantine, isolation, and disinfection, which 
 have been directed to control their spread, and that, as all substantial decreases 
 in their mortality-rates occurred before such measures were seriously attempted, 
 decline in their mortality and increase in their morbidity were altogether 
 independent of interferences of this character. It can not be denied, however, 
 that the application of these measures in recent times may not have often 
 served to protect certain individuals and groups of individuals from attacks. 
 On the other hand, it would be idle, in the face of established facts to the 
 contrary, to claim that on the whole these methods have in any serious degree 
 influenced the natural courses of these diseases in the community. That the 
 course of small-pox has been modified, but not controlled, by vaccination seems 
 certain. 
 
 In regard to the question of morbidity, as true now as when written in 1838, 
 are the words of Dr. John H. Briscoe, consulting physician to the board of 
 health: 
 
 “We have had scarlet fever lingering with us, but how long it is to remain the 
 undersigned has no speculation to offer, nor has he on the general character of epidemic, 
 contagious, or infectious disease, more than, that small-pox will continue to recur 
 locally as an endemic or epidemic disease until vaccination has become universal 
 throughout the land; that scarlet fever and measles occur under no fixed laws, and both 
 seem disposed to abide with us.” 
 
 To what degrees the changes resulting in the present status of the attack ana 
 fatality rates of these diseases have resulted from modifications of the several 
 viruses, of the population, and of the environment are matters of speculation. 
 From the standpoint of natural selection as a possible influence, it may be 
 significant that the highest incidence and the highest death-rates for those 
 members of the group which have been most fatal have been among individuals 
 too young to have had progeny. In consequence, those dying of any one of 
 
334 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 these diseases have, in general, failed to perpetuate a specially susceptible 
 strain, and survivors of attacks have had the advantage of transmitting to 
 offspring their natural and acquired resistance to death from that particular 
 disease. 
 
 For diseases the chances of general dissemination of whose viruses are depen¬ 
 dent very largely upon the convalescent carriers—and it seems probable that 
 all the members of this group belong to this class—it is obvious that high 
 case-fatality rates must affect unfavorably and low fatality-rates must effect 
 favorably, their opportunities to spread in the community. Any logically satis¬ 
 factory explanation of the variation in morbidity and mortality exhibited by 
 these diseases must account for the conditions, environmental and other, that, 
 on the one hand, affect the aggressiveness of the organisms to attack and to 
 kill, and, on the other hand, that raise or lower the resistance of the population. 
 Definite data for framing such an explanation are wholly lacking. 
 
 ACUTE INFLAMMATORY AFFECTIONS OF THE 
 
 RESPIRATORY TRACT. 
 
 Under this heading are grouped whooping-cough, diphtheria, and bronchitis 
 and pneumonia. The first two have long been recognized clinically and statisti¬ 
 cally as definite specific diseases. 
 
 Whooping-cough, readily distinguished in typical cases by the characteristic 
 cough, is hardly likely to be confused clinically to a serious degree with other 
 affections. It has no doubt been confused in the statistical nosology, however, 
 with its chief complications—bronchitis and pneumonia. The discovery in 
 1910 of B. 'pertussis, its probable causative agent, has from the practical stand¬ 
 point added nothing of importance to exactness of diagnosis. 
 
 Diphtheria, on the other hand, until the discovery of its cause, B. diphtherice, 
 in 1884, was the subject of much confusion with other acute affections of the 
 throat, nose, and larynx. Hardly ever mistaken when in epidemic form, doubt¬ 
 less in isolated cases it has been confused clinically and therefore statistically 
 with other affections. Again, on account of the not infrequent occurrence of 
 pneumonia as a complication, it is likely that the latter has been credited 
 with some deaths due primarily to the former. At the present day there is 
 perhaps no other serious infectious disease whose natural history is so fully 
 known. While other inflammatory diseases of the organs usually affected by 
 diphtheria and whooping-cough are common enough clinically, they are, rela¬ 
 tively speaking, rarely fatal. Thus they have not seriously affected the accuracy 
 of the mortality figures for these two diseases. While from time to time, from 
 the earliest years, a few deaths have been classified under such headings as 
 inflammation of the throat or larynx, tonsillitis, and cynanche tonsillaris, they 
 were never sufficiently numerous to warrant special consideration. One epi¬ 
 demic of so-called septic sore throat, due to streptococcus and spread largely 
 by the milk of a particular dairy, occurred in December 1911, and January, 
 February, and March 1912. According to conservative estimates, the cases must 
 have numbered over 2,000. The deaths, as certified under a variety of headings 
 suggested by the most prominent lesions, such as appendicitis, broncho-pneu¬ 
 monia, erysipelas, and peritonitis, as well as septic sore throat, numbered 28. 
 
FEBRILE DISEASES 
 
 335 
 
 The two remaining members of this group have rested on less secure ground. 
 Though possessing leading symptoms, they lack absolutely characteristic symp¬ 
 toms, such as the whoop of whooping-cough and the loss of voice and the pecu¬ 
 liar interference with breathing of typical laryngeal diphtheria. Affecting 
 organs not subject to direct inspection and requiring so often for differential 
 diagnosis the use of methods of physical exploration acquired with relative 
 difficulty, they were doubtless frequently mistaken or overlooked. These 
 methods, percussion and auscultation, though perfected by Laennec early in the 
 nineteenth century, were but slowly learned with precision and widely adopted 
 in Baltimore. It is doubtful if, until William Power’s return from Paris in 
 1838, there was a single adept in these methods in the city. In his short career, 
 though he trained the talented T. H. Buckler and the band of bright students 
 who gathered around them at the almshouse, he could not have trained any 
 large proportion of the medical students and older practitioners of his day. As 
 late as 1890 but a small proportion of the students at the Baltimore medical 
 schools had the opportunity to become expert in the use of these methods. The 
 rest picked them up as best they could. It was not until well after 1850 that any 
 large proportion of the practitioners in Baltimore had any other means than 
 those afforded by common clinical symptoms, such as chest pain, shortness of 
 breath, fever, and the character of the respiration and expectoration for making 
 differential diagnoses of the acute diseases of the bronchi, lungs, and plurae. 
 Hence it was that pleurisy occupied such a prominent position, that broncho¬ 
 pneumonia, and probably bronchitis, was so long hid in catarrhal fever, and 
 that bronchitis was differentiated so late. It is impossible to determine whether 
 the terms “ inflammation of the bronchi ” and “ inflammation of the lungs ” 
 belonged to medical nosology or were simply statistical rubrics of the health 
 department, designed to simplify and shorten the lists of the causes of death. 
 
 Bronchitis alone is probably rarely fatal, and the great bulk of the deaths 
 attributed to it must surely have been due to pneumonia, usually perhaps to 
 one of the forms of broncho-pneumonia in the pathological anatomical sense. 
 
 Acute pneumonia or acute inflammation of the lungs (involving often, if not 
 usually, the adjacent pleura) is not a single and specific disease, judged either 
 from the standpoint of the portion or portions of the lung tissue involved or 
 from the character of the exudations and other forms of inflammatory lesions. 
 
 Neither bronchitis nor pneumonia in its several forms is specific in the etio¬ 
 logical sense. Both are caused by a variety of bacteria—bacilli and cocci—and 
 the same organism does not always give rise to the same lesions. Only one form 
 of pneumonia, the lobar or croupous, seems to be specific in the etiological 
 sense. It is almost if not always associated with the presence in the affected 
 portion of the lung of a particular species of micro-organism, the pneumococ¬ 
 cus. At least four different varieties of the pneumococcus are known, and these 
 differ among themselves not only in frequency of ocurrence in pneumonia, but 
 in virulence. The lethal and perhaps the invasive capacity of each type is by 
 no means constant. Again, not only may more than one type be present in a 
 particular case of pneumonia, but bacteria of other species as well. Lobar 
 pneumonia, probably usually primary, occurs not infrequently as a complica¬ 
 tion of other diseases, for the most part the same as will be enumerated for 
 broncho-pneumonia. 
 
336 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 The peculiar type of lung infection characterized by lobar consolidation and 
 simulating lobar pneumonia., but due to B. mucosus, is of too rare occurrence 
 to be statistically important. Bronchitis and broncho-pneumonia, the latter 
 term a gather-all for several distinct types of lesions having in common the 
 involvment of both the bronchial and lung tissues, may be caused by a variety 
 of cocci and bacilli. The most important of these are the streptococci, staphy¬ 
 lococci, pneumococci, B. mucosus, and B. pfiefferi (or B. influenza). These 
 and others may be present alone or in various combinations. While broncho¬ 
 pneumonia occurs very commonly as a complication of some other disease, 
 acute or chronic, it is not infrequently a primary disease. The most common 
 acute diseases which it complicates are the so-called exanthematous diseases, 
 particularly measles and influenza, whooping-cough, diphtheria, epidemic 
 meningitis, and typhoid and typhus fevers. In many cases of wound infection, 
 including puerpural fever, and of primary suppurative disorders, as appendi¬ 
 citis for instance, broncho-pneumonia is a common complication. It also occurs 
 in such specific infections as glanders and anthrax, but usually as a part of 
 the disease. Both broncho and lobar pneumonia occur as terminal events in 
 the course of such chronic diseases as nephritis, arteriosclerosis, heart disease, 
 cirrhosis of the liver, diabetes, tumor, leucaemia, and the like. In severe acute 
 malaria pneumonia often occurred, but according to the best evidence as a 
 complication. Finally, pathological anatomists have shown that even accom¬ 
 plished physicians are frequently unable to distinguish successfully between 
 broncho-pneumonia and lobar pneumonia. 
 
 A very strong body of evidence, drawn from both clinical observation and 
 laboratory experiment, indicates that all of these affections are in general spread 
 by contact from person to person. Opportunity for transfer in this way is 
 abundant, for the causative agents are present in the discharges from the air- 
 passages and in the mouths and noses not only of their victims during illness, 
 but often long after convalescence. The organisms of diphtheria and of lobar 
 pneumonia have often been isolated from the mouths and throats of persons who 
 have never been ill with these diseases. Indeed this “ healthy carrier 99 state, 
 common enough among those recently exposed to persons with these diseases, 
 may occur in individuals who have never consciously been so associated. Innu¬ 
 merable chances occur for the transfer of the causes of all these affections by 
 kissing, by the hands, by clothing, by utensils, and in particular by coughing. 
 While it is doubtful if any of them are water-borne, this possibility has not 
 been excluded. The possibility of the action of insects as mechanical carriers 
 at certain seasons must be recognized. Milk has been shown to be an occasional 
 vehicle of transfer for diphtheria bacilli and streptococci. All the evidence at 
 hand tends to show that the causative agents of diphtheria, whooping-cough, 
 and lobar pneumonia do not, under ordinary conditions at least, long survive 
 separation from the human being as host. Streptococci, staphylococci, and 
 B. mucosus are more resistant to outside influences, and in consequence have a 
 wide range of distribution. B. pfieff eri does not apparently long survive separa¬ 
 tion from its favorite human habitat. These diseases must, then, be classed as 
 contact diseases in the usually accepted sense. 
 
FEBRILE DISEASES 
 
 337 
 
 WHOOPING-COUGH. 
 
 Whooping-cough appears as a cause of death in the mortality records for 1812 
 and is credited with deaths in each succeeding year. Endemically intrenched 
 when the present record begins, it has maintained this position uninterruptedly. 
 Judged from the wide fluctuations in the annual mortality-rates (table 60, 
 graph 17), its lethal capacity in relation to the Baltimore population has been 
 marked with great irregularity. Its highest annual death rate, 215, was in 
 1816, and the highest rates subsequently attained were in 1819, 1833, 1867, 
 and 1877, 141, 140, 91, and 95, respectively. Rates between 60 and 70 occurred 
 in 7 years (1813, 1826, 1837, 1839, 1847, 1856, and 1870), between 50 and 60 
 
 Graph 17 (from table 60). Annual crude mortality-rates from whooping- 
 cough, diphtheria, and pneumonia, from 1812 to 1920, inclusive. 
 
 in 5 years (1823, 1828, 1851, 1853, and 1859), and between 40 and 50 in 15 
 years (1814, 1820, 1821, 1836, 1842, 1844, 1845, 1852, 1860, 1861, 1868, 1873, 
 1874, 1880, and 1918). 
 
 Very characteristic of its course has been the occurrence of unusually high 
 death-rates for 2 or 3 years in sequence, followed by intermediate periods of 
 low rates covering one or even several years. These short outbreaks do not, 
 however, follow any constant law. After an exceptionally high outbreak in one 
 year, particularly if it be preceded by a year or two of low rates, the succeeding 
 drop is apt to be correspondingly low. This is well illustrated in 1816, 1833, 
 1905, and 1918. The course of the curve is, therefore, very irregular, and only 
 rarely, as in 1843-1844, 1851-1855, 1858-1861, 1881-1883, and 1890-1891, 
 does the disease exhibit a tendency to stabilize about a fixed level. A marked 
 
Table 60 . —Number oj deaths and rate of death, per 100,000 living inhabitants, from whooping-cough, diphtheria, pneumonia, bronchitis, and total 
 
 acute diseases of the respiratory tract, and percentage of total deaths, from 1812 to 1920, inclusive. 
 
 338 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 
 
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FEBRILE DISEASES 
 
 339 
 
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340 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 decline in the mortality-rates began about 1880, but the persistence of con¬ 
 siderable annual fluctuations continued. 
 
 The curve of the death-rates averaged for 5-year periods (table 61, graph 18) 
 shows a marked rise from a comparatively low rate in 1812-1815 to a rate of 
 86 in 1816-1820, with a sharp fall to 33 in 1821-1825. For the next 25 years 
 the averaged rates change but little, but from 1851 to 1860 they spring to about 
 45, followed, however, in 1861-1865, by a sharp fall to 29. Another rise in 
 1866-1870 is followed by a decline in 1871-1875 and another rise in 1876- 
 1880. From the latter date, except for a slight ascent in 1886-1890, the descent 
 in the rates is sharp to the low rate of 11 in 1896-1900. During the last 20 
 
 Table 61. —Average rate of death by 6- and 10-year periods from acute diseases of the 
 
 respiratory tract, from 1812 to 1920, inclusive: 
 
 Period. 
 
 Pneumonia and 
 bronchitis. 
 
 Whooping-cough. 
 
 Diphtheria. 
 
 Total. 
 
 By 5-year 
 periods. 
 
 By 10-year 
 periods. 
 
 By 5-year 
 periods. 
 
 By 10-year 
 periods. 
 
 By 5-vear 
 
 periods. 
 
 By 10-year 
 
 periods. 
 
 By 5-year 
 
 periods. 
 
 By 10-year 
 
 periods. 
 
 1812-15 . 
 
 193 
 
 • • • 
 
 39 
 
 • • • 
 
 86 
 
 • • • 
 
 318 
 
 • • • 
 
 1816-20 . 
 
 132 
 
 159 ' 
 
 86 
 
 65 
 
 95 
 
 91 
 
 314 
 
 316 
 
 1821-25 . 
 
 75 
 
 • • • 
 
 33 
 
 • • • 
 
 63 
 
 • • • 
 
 171 
 
 • • • 
 
 1826-30 . 
 
 79 
 
 77 
 
 37 
 
 35 
 
 37 
 
 50 
 
 152 
 
 162 
 
 1831-35 . 
 
 108 
 
 • • • 
 
 34 
 
 • • • 
 
 36 
 
 • • • 
 
 178 
 
 • • • 
 
 1836-40 . 
 
 119 
 
 113 
 
 38 
 
 36 
 
 41 
 
 39 
 
 198 
 
 188 
 
 1841-45 . 
 
 132 
 
 ... 
 
 36 
 
 ... 
 
 41 
 
 • • • 
 
 209 
 
 ... 
 
 1846-50 . 
 
 150 
 
 141 
 
 35 
 
 35 
 
 90 
 
 65 
 
 275 
 
 242 
 
 1851-55 . 
 
 165 
 
 • • • 
 
 45 
 
 • • • 
 
 98 
 
 • • • 
 
 309 
 
 • • • 
 
 1856-60 . 
 
 132 
 
 149 
 
 44 
 
 45 
 
 104 
 
 101 
 
 280 
 
 294 
 
 1861-65 . 
 
 97 
 
 • • • 
 
 29 
 
 • • • 
 
 156 
 
 • • • 
 
 281 
 
 • • • 
 
 1866-70 . 
 
 147 
 
 122 
 
 48 
 
 38 
 
 116 
 
 136 
 
 310 
 
 296 
 
 1871-75 . 
 
 188 
 
 • • • 
 
 33 
 
 • • • 
 
 99 
 
 • • • 
 
 320 
 
 • • • 
 
 1876-80 . 
 
 178 
 
 183 
 
 39 
 
 36 
 
 136 
 
 117 
 
 352 
 
 336 
 
 1881-85 . 
 
 203 
 
 • • • 
 
 21 
 
 • • • 
 
 195 
 
 • • • 
 
 418 
 
 • • • 
 
 1886-90 . 
 
 229 
 
 216 
 
 22 
 
 22 
 
 67 
 
 131 
 
 319 
 
 368 
 
 1891-95 . 
 
 277 
 
 • • • 
 
 16 
 
 ... 
 
 70 
 
 • • • 
 
 363 
 
 • • • 
 
 1896-1900 . 
 
 267 
 
 272 
 
 11 
 
 14 
 
 66 
 
 68 
 
 343 
 
 353 
 
 1901-05 . 
 
 263 
 
 • • • 
 
 11 
 
 • • • 
 
 26 
 
 ... 
 
 300 
 
 • • • 
 
 1906-10 . 
 
 224 
 
 243 
 
 15 
 
 13 
 
 14 
 
 20 
 
 253 
 
 276 
 
 1911-15 . 
 
 222 
 
 ... 
 
 8 
 
 • • • 
 
 14 
 
 • • • 
 
 244 
 
 • • • 
 
 1916-20 . 
 
 305 
 
 264 
 
 13 
 
 11 
 
 13 
 
 13 
 
 332 
 
 288 
 
 years the rate has fluctuated between 8 and 15. When the rates (table 61 and 
 graph 19) are averaged for 10-year periods, some of the irregularities above 
 noted are eliminated and the course of the curve is somewhat modified. Starting 
 in 1812-1820, from the high average rate of 65, there is an abrupt drop in 
 1821-1830 to 35, an average rate about maintained the next 20 years. From 
 the average rate of 45 attained in 1851-1860, there is a gradual decline to 36 
 in 1871-1880 and a sharp decline to 14 in 1891-1900, and by 1911-1920, the 
 average rate was 11. 
 
 These curves, obtained by averaging the annual death-rates by 5- and 10-year 
 periods, give essentially the same picture of the course of the force of mortality 
 of whooping-cough in Baltimore during a period of 109 years. Until 1825, 
 
FEBRILE DISEASES 
 
 341 
 
 % 
 
 Graph 18 (from table 61). Crude mortality-rates from whooping-cough, 
 diphtheria, and pneumonia, averaged by 5-year periods, from 1812 to 1920, 
 inclusive. 
 
 Graph 19 (from table 61). Crude mortality-rates from whooping-cough, 
 diphtheria, and pneumonia, averaged by 10-year periods, from 1812 to 1920, 
 inclusive. 
 
342 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 perhaps relatively new to the population, this disease possessed a lethal capacity 
 of a high order, and then for 25 years became stabilized at a much lower mor¬ 
 tality-rate. From 1850 to 1870 this level was overshot, but, by 1875, it was 
 again reached. Since the latter date the average rate has sunk by gradations 
 to a level lower by six times that of the nine years 1812-1820. 
 
 The influence of color, sex, and age upon the lethal force of whooping-cough 
 in 1910 and 1920 is illustrated in tables 62 and 63. From these it is clear that 
 the disease is over four times as fatal for negroes as for whites, taking the two 
 
 Table 62. — Number of deaths and the rate of death, per 100,000 living inhabitants, from 
 whooping-cough and diphtheria, according to age, color, and sex, for 1910. 
 
 WHOOPING-COUGH. 
 
 D = death. R = rate. 
 
 
 Total. 
 
 
 
 White. 
 
 
 
 
 
 Colored. 
 
 
 
 Age-period. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 Under 1 year. 
 
 43 
 
 420 
 
 30 
 
 337 
 
 18 
 
 401 
 
 12 
 
 273 
 
 13 
 
 964 
 
 8 
 
 1168 
 
 5 
 
 754 
 
 Between 1 and 2 yrs. 
 
 15 
 
 156 
 
 9 
 
 106 
 
 1 
 
 23 
 
 8 
 
 195 
 
 6 
 
 532 
 
 4 
 
 718 
 
 2 
 
 351 
 
 2 to 4 years. 
 
 20 
 
 62 
 
 7 
 
 25 
 
 1 
 
 7 
 
 6 
 
 43 
 
 13 
 
 313 
 
 4 
 
 199 
 
 9 
 
 420 
 
 5 to 9 years. 
 
 4 
 
 8 
 
 1 
 
 2 
 
 1 
 
 5 
 
 • • • 
 
 • • • 
 
 3 
 
 47 
 
 2 
 
 65 
 
 1 
 
 30 
 
 Under 10 years. 
 
 82 
 
 81 
 
 47 
 
 53 
 
 21 
 
 47 
 
 26 
 
 59 
 
 35 
 
 268 
 
 18 
 
 285 
 
 17 
 
 252 
 
 10 to 19 years. 
 
 1 
 
 1 
 
 
 
 
 
 
 
 1 
 
 7 
 
 1 
 
 17 
 
 • • • 
 
 • • • 
 
 20 to 29 years. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 30 to 39 years. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 40 years and over... 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Total . 
 
 83 
 
 15 
 
 47 
 
 10 
 
 21 
 
 9 
 
 26 
 
 11 
 
 36 
 
 42 
 
 19 
 
 48 
 
 17 
 
 37 
 
 DIPHTHERIA. 
 
 Under 1 year. 
 
 4 
 
 39 
 
 3 
 
 34 
 
 2 
 
 45 
 
 1 
 
 23 
 
 1 
 
 74 
 
 1 
 
 140 
 
 • • • 
 
 • • • 
 
 Between 1 and 2 yrs. 
 
 13 
 
 135 
 
 12 
 
 141 
 
 7 
 
 160 
 
 5 
 
 122 
 
 1 
 
 89 
 
 • • • 
 
 • •• 9 
 
 1 
 
 175 
 
 2 to 4 years. 
 
 31 
 
 96 
 
 31 
 
 111 
 
 19 
 
 135 
 
 12 
 
 86 
 
 
 
 
 
 
 
 5 to 9 years. 
 
 11 
 
 22 
 
 11 
 
 25 
 
 3 
 
 14 
 
 8 
 
 37 
 
 
 
 
 
 
 
 Under 10 years. 
 
 59 
 
 58 
 
 57 
 
 64 
 
 31 
 
 69 
 
 26 
 
 59 
 
 2 
 
 15 
 
 1 
 
 16 
 
 1 
 
 15 
 
 10 to 19 years. 
 
 1 
 
 1 
 
 1 
 
 1 
 
 • • • 
 
 • • • 
 
 1 
 
 2 
 
 
 
 
 
 
 
 20 to 29 years. 
 
 1 
 
 1 
 
 
 
 
 
 
 
 1 
 
 5 
 
 1 
 
 11 
 
 • • • 
 
 ... 
 
 30 to 39 years. 
 
 3 
 
 3 
 
 1 
 
 1 
 
 1 
 
 3 
 
 • • • 
 
 • • • 
 
 2 
 
 13 
 
 1 
 
 13 
 
 1 
 
 12 
 
 40 years and over... 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Total . 
 
 64 
 
 11 
 
 59 
 
 12 
 
 32 
 
 14 
 
 27 
 
 11 
 
 5 
 
 6 
 
 3 
 
 8 
 
 2 
 
 4 
 
 years together, somewhat more fatal for white males than for white females, 
 and about equally fatal for males and females among negroes. The effect of age 
 is striking. There was but 1 death in individuals over the tenth year of age, and 
 nearly the whole mortality was confined to the age period 0 to 4 years, and over 
 half of it to the first year of life. The experience of these two years in regard 
 to the greater mortality in negroes as compared with whites is confirmed by that 
 of the 16-year period, 1905-1920, when, of the 1,058 deaths attributed to 
 whooping-cough, 598 were in whites and 460 were in negroes, a ratio of 1.3 to 
 1, while the proportion of whites to negroes in the population was 5.42 to 1. 
 
FEBRILE DISEASES 
 
 343 
 
 On the assumption that throughout the course of the disease in Baltimore the 
 fatality in whooping-cough has been largely if not entirely restricted to the 
 population in age-group 0-9 years, mortality rates calculated on this basis for 
 the census years 1830 to 1920, inclusive, should be instructive. These are given 
 in table 64. It is obvious that in a disease whose fatality has varied so greatly 
 from year to year, the rates thus obtained for these particular years, even 
 though based upon the averages of several years, can not be taken as fully 
 representative of the respective periods in which they lie. But, considered 
 
 Table 63. —Number of deaths and rate of death, per 100,000 living inhabitants, from 
 whooping-cough and diphtheria, according to age, color, and sex, for 1020. 
 
 WHOOPING-COUGH. 
 D = death. R = rate. 
 
 
 
 
 
 White. 
 
 
 
 
 
 Colored. 
 
 
 
 Age-groups. 
 
 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 Under 1 year. 
 
 34 
 
 229 
 
 18 
 
 140 
 
 9 
 
 136 
 
 9 
 
 143 
 
 16 
 
 813 
 
 6 
 
 627 
 
 10 
 
 989 
 
 1 to 4 years. 
 
 20 
 
 37 
 
 13 
 
 27 
 
 8 
 
 33 
 
 5 
 
 21 
 
 7 
 
 109 
 
 3 
 
 96 
 
 4 
 
 121 
 
 0 to 4 years. 
 
 54 
 
 78 
 
 31 
 
 51 
 
 17 
 
 55 
 
 14 
 
 32 
 
 23 
 
 275 
 
 9 
 
 221 
 
 14 
 
 325 
 
 5 to 9 years. 
 
 2 
 
 3 
 
 1 
 
 2 
 
 1 
 
 3 
 
 • • • 
 
 • • • 
 
 1 
 
 12 
 
 • • • 
 
 • • • 
 
 1 
 
 24 
 
 0 to 9 years. 
 
 56 
 
 42 
 
 32 
 
 27 
 
 18 
 
 30 
 
 14 
 
 24 
 
 24 
 
 146 
 
 9 
 
 113 
 
 15 
 
 176 
 
 10 to 19 years. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 20 to 29 years. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 30 to 39 years. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 40 years and over.... 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Total . 
 
 56 
 
 8 
 
 32 
 
 5 
 
 18 
 
 6 
 
 14 
 
 4 
 
 24 
 
 22 
 
 9 
 
 17 
 
 15 
 
 27 
 
 DIPHTHERIA. 
 
 Under 1 year. 
 
 10 
 
 67 
 
 10 
 
 78 
 
 5 
 
 76 
 
 5 
 
 80 
 
 
 
 
 
 
 
 1 to 4 years. 
 
 72 
 
 132 
 
 68 
 
 141 
 
 30 
 
 124 
 
 38 
 
 159 
 
 4 
 
 62 
 
 3 
 
 96 
 
 1 
 
 30 
 
 0 to 4 years. 
 
 82 
 
 118 
 
 78 
 
 128 
 
 35 
 
 114 
 
 43 
 
 99 
 
 4 
 
 48 
 
 3 
 
 74 
 
 1 
 
 23 
 
 5 to 9 years. 
 
 15 
 
 23 
 
 15 
 
 27 
 
 9 
 
 31 
 
 6 
 
 22 
 
 
 
 
 
 
 
 0 to 9 years. 
 
 97 
 
 72 
 
 83 
 
 71 
 
 44 
 
 74 
 
 49 
 
 84 
 
 4 
 
 24 
 
 3 
 
 38 
 
 1 
 
 12 
 
 10 to 19 years. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 20 to 29 years. 
 
 2 
 
 1 
 
 2 
 
 2 
 
 • • • 
 
 • • • 
 
 2 
 
 3 
 
 
 
 
 
 
 
 30 to 39 years. 
 
 1 
 
 1 
 
 1 
 
 1 
 
 1 
 
 2 
 
 
 
 
 
 
 
 
 
 40 years and over.... 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Total . 
 
 100 
 
 14 
 
 96 
 
 15 
 
 45 
 
 14 
 
 51 
 
 16 
 
 4 
 
 4 
 
 3 
 
 6 
 
 1 
 
 2 
 
 broadly, these rates bring out more clearly the relatively high mortality that 
 obtained in the sixth, seventh, eighth, and ninth decennia of the nineteenth 
 century, the subsequent decline from this high level, and above all the fact 
 that to estimate correctly the real meaning of the changes observed afterward 
 in the course of the crude rates, corrections must be made for differences which 
 have taken place in the age distribution of the population. When this allowance 
 is made, it is found that the force of mortality of this disease, after a high 
 accession in the intermediate period, declined by 1890 to about the level of 
 1830, from which it has departed significantly only in the last 10 years. 
 
344 PUBLIC HEALTH ADMINISTRATION", ETC., IN BALTIMORE 
 
 Data for morbidity by months and years are available since 1897, and are 
 presented in table 65. All the evidence at hand indicates that case reporting has 
 never approached completeness. The testimony of health wardens of long experi¬ 
 ence is that many cases are never seen by physicians and that a physician 
 called to see the first case in a family of children often does not see and report 
 the secondary cases. Cases are never reported by parents directly. It is believed 
 that case reporting since 1910 has reflected the actual incidence of the disease 
 much more accurately than before that date. There is no evidence, that report¬ 
 ing was more accurate between 1916 and 1920 than it was between 1911 and 
 1915. Though in no year since 1897 do the recorded figures represent actual 
 occurrences, relatively, they are of some importance for determining varia¬ 
 tions in incidence by months and by years. In the 24 years under review, the 
 
 Table 64.— Number of deaths and the rate of death, per 
 100,000 living inhabitants under 10 years of age, from 
 whooping-cough and diphtheria, for the decennia 
 1830 to 1920, inclusive* 
 
 Year. 
 
 Whooping-cough. 
 
 Diphtheria. 
 
 Deaths. 
 
 Rate. 
 
 Deaths. 
 
 Rate. 
 
 1830 . 
 
 17 
 
 82 
 
 23 
 
 Ill 
 
 1840 . 
 
 39 
 
 146 
 
 36 
 
 135 
 
 1850 . 
 
 55 
 
 123 
 
 148 
 
 332 
 
 1860 . 
 
 106 
 
 189 
 
 238 
 
 424 
 
 1870 . 
 
 96 
 
 147 
 
 273 
 
 419 
 
 1880 . 
 
 107 
 
 144 
 
 611 
 
 812 
 
 1890 . 
 
 88 
 
 96 
 
 307 
 
 336 
 
 1900 . 
 
 43 
 
 42 
 
 253 
 
 249 
 
 1910 . 
 
 86 
 
 85 
 
 69 
 
 68 
 
 1920 . 
 
 40 
 
 30 
 
 123 
 
 92 
 
 * The number of deaths for each decennium is a 3- 
 year average of that obtaining in the decennial year and 
 in those years immediately preceding and following, 
 except in 1920, when the average is for 1919 and 1920 only. 
 
 rates of incidence have varied considerably from year to year and have shown 
 a wide margin between the highest and the lowest levels attained. Conspicuous 
 examples of such deviations in the rates were, in the earlier period, 15 in 1904 
 and 120 in 1909, and in the later period, 42 in 1915 and 508 in 1920. The 
 rates averaged for 5-year periods were 46 and 47, respectively, for 1897-1900 
 and 1901-1905, 75 for 1906-1910, 62 for 1911-1915, and 237 for 1916-1920. 
 The annual rates averaged for the 10-year periods 1901-1910 and 1911-1920 
 were 61 and 149, respectively. The increase in recorded incidence of the disease 
 since 1916 is particularly striking. It will be noted that after two years of 
 exceptionally high rates, 230 and 209, respectively, the former the highest ever 
 recorded up to that time, the rate in 1918 jumped to 508. Falling to 91 in 
 1919, the morbidity-rate rose to 148 in 1920. While the general increase in 
 the morbidity-rates since 1910 was doubtless in some measure due to more 
 complete case reporting in this period as compared with the years previous to 
 this date, the wide annual fluctuations characteristic of both periods can not be 
 
FEBRILE DISEASES 
 
 345 
 
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 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 so explained. Whatever the actual and the relative values of the rates previous 
 to 1910, the evidence at hand indicates that at least the major part of the 
 increase in the rates between 1916 and 1920, as compared with the period 1911- 
 1915, was due to a real rise in incidence, and not alone to fuller case reporting. 
 
 Table 66 —Number of cases and the rate of morbidity, per 100,000 living inhabitants in 1920, 
 for whooping-cough and diphtheria, according to age, sex, and color, for 1921. 
 
 WHOOPING COUGH. 
 
 O -- cases. R — rate. 
 
 Age-groups. 
 
 Total. 
 
 White. 
 
 Colored. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 Total. 
 
 Male. 
 
 Fem, 
 
 C 
 
 R 
 
 C 
 
 R 
 
 C 
 
 R 
 
 C 
 
 R 
 
 C 
 
 R 
 
 C 
 
 R 
 
 c 
 
 R 
 
 Under 1 year. 
 
 396 
 
 2666 
 
 349 
 
 2709 
 
 196 
 
 2970 
 
 153 
 
 2435 
 
 47 
 
 2388 
 
 22 
 
 2299 
 
 25 
 
 2473 
 
 1 to 4 years 
 
 1444 
 
 2649 
 
 1381 
 
 2871 
 
 669 
 
 2771 
 
 712 
 
 2973 
 
 63 
 
 983 
 
 28 
 
 899 
 
 35 
 
 1063 
 
 0 to 4 years 
 
 1840 
 
 2653 
 
 1730 
 
 2837 
 
 865 
 
 2813 
 
 865 
 
 1996 
 
 110 
 
 1313 
 
 50 
 
 1229 
 
 60 
 
 1394 
 
 5 to 9 years 
 
 1265 
 
 1961 
 
 1205 
 
 2136 
 
 589 
 
 2061 
 
 616 
 
 2213 
 
 60 
 
 744 
 
 25 
 
 648 
 
 35 
 
 832 
 
 0 to 9 years 
 
 3105 
 
 2320 
 
 2935 
 
 2500 
 
 1454 
 
 2451 
 
 1481 
 
 2560 
 
 170 
 
 1034 
 
 75 
 
 946 
 
 95 
 
 1116 
 
 10 to 19 years 
 
 142 
 
 115 
 
 126 
 
 117 
 
 63 
 
 119 
 
 63 
 
 115 
 
 16 
 
 100 
 
 8 
 
 113 
 
 8 
 
 90 
 
 20 to 29 years 
 
 8 
 
 6 
 
 8 
 
 7 
 
 
 
 8 
 
 13 
 
 
 
 
 
 
 
 30 to 39 years 
 
 12 
 
 10 
 
 12 
 
 12 
 
 6 
 
 12 
 
 6 
 
 12 
 
 
 
 
 
 
 
 40 to 49 years 
 
 2 
 
 2 
 
 2 
 
 3 
 
 1 
 
 3 
 
 1 
 
 3 
 
 
 
 
 
 
 
 50 to 59 years 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 60 to 69 years 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 70 to 79 years 
 
 2 
 
 13 
 
 2 
 
 15 
 
 
 
 2 
 
 27 
 
 
 
 
 
 
 
 80 years and 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 over . 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Total ... 
 
 3271 
 
 446 
 
 3085 
 
 493 
 
 1524 
 
 494 
 
 1561 
 
 493 
 
 186 
 
 171 
 
 83 
 
 156 
 
 103 
 
 186 
 
 DIPHTHERIA. 
 
 Under 1 year. 
 
 48 
 
 323 
 
 38 
 
 295 
 
 21 
 
 318 
 
 17 
 
 271 
 
 10 
 
 508 
 
 2 
 
 209 
 
 8 
 
 791 
 
 1 to 4 years 
 
 554 
 
 1016 
 
 537 
 
 1116 
 
 291 
 
 1205 
 
 246 
 
 1027 
 
 17 
 
 265 
 
 13 
 
 418 
 
 4 
 
 121 
 
 0 to 4 years 
 
 602 
 
 868 
 
 575 
 
 943 
 
 312 
 
 1015 
 
 263 
 
 607 
 
 27 
 
 322 
 
 15 
 
 369 
 
 12 
 
 279 
 
 5 to 9 years 
 
 508 
 
 788 
 
 493 
 
 874 
 
 266 
 
 931 
 
 227 
 
 815 
 
 15 
 
 186 
 
 10 
 
 259 
 
 5 
 
 119 
 
 0 to 9 years 
 
 1110 
 
 8293 
 
 1068 
 
 910 
 
 578 
 
 974 
 
 490 
 
 844 
 
 42 
 
 255 
 
 25 
 
 315 
 
 17 
 
 200 
 
 10 to 19 years 
 
 185 
 
 150 
 
 174 
 
 161 
 
 84 
 
 159 
 
 90 
 
 164 
 
 11 
 
 69 
 
 5 
 
 71 
 
 6 
 
 68 
 
 20 to 29 years 
 
 75 
 
 52 
 
 72 
 
 60 
 
 23 
 
 39 
 
 49 
 
 81 
 
 3 
 
 11 
 
 • • • • 
 
 • • • • 
 
 3 
 
 22 
 
 30 to 39 years 
 
 38 
 
 31 
 
 36 
 
 36 
 
 9 
 
 18 
 
 27 
 
 54 
 
 2 
 
 9 
 
 • • • • 
 
 • • • • 
 
 2 
 
 19 
 
 40 to 49 years 
 50 to 59 years 
 60 to 69 years 
 70 to 79 years 
 80 years and 
 
 8 
 
 9 
 
 8 
 
 10 
 
 3 
 
 8 
 
 5 
 
 13 
 
 
 
 
 
 
 
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 8 
 
 5 
 
 9 
 
 1 
 
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 4 
 
 14 
 
 
 
 
 
 
 
 1 
 
 3 
 
 1 
 
 3 
 
 
 1 
 
 6 
 
 
 
 
 
 
 
 1 
 
 7 
 
 1 
 
 8 
 
 1 
 
 18 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 over . 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Total ... 
 
 1423 
 
 194 
 
 1365 
 
 218 
 
 699 
 
 227 
 
 666 
 
 210 
 
 58 
 
 53 
 
 30 
 
 56 
 
 28 
 
 50 
 
 From table 66 it appears that, so far as may be judged from the reported cases 
 in 1921, the incidence of whooping-cough was confined almost entirely to indi¬ 
 viduals under the tenth year. The attack-rate was notably high under 1 year 
 of age, and higher in the first than in the second 5 years of life. Morbidity was 
 much greater among whites than among negroes, and somewhat greater among 
 females than among males in the black race. 
 
FEBRILE DISEASES 
 
 347 
 
 Kates for case fatality are, of course, open to the same criticism as those for 
 morbidity. Extreme examples of these variations are 3 per cent in 1919 and 
 32 per cent in 1906. They have by no means risen and fallen directly with 
 the morbidity-rates, for whereas, lower case-fatality rates have often synchro¬ 
 nized with higher morbidity-rates, the reverse has also frequently occurred 
 (table 65). As averaged for 5-year periods from 1901 to 1920, the case-fatality 
 rates were 26, 19, 13, and 5 per cent, respectively. Has whooping-cough in 
 the last 15 years, as the official figures seem to show, become more prevalent 
 and relatively less lethal, or, otherwise expressed, has a greater increase in 
 invasive capacity been associated with a corresponding decrease in mortality 
 force ? It has been shown that differences in accuracy of case reporting can not 
 be held responsible for all of the variations in morbidity. There were no marked 
 differences in the age, sex, and race distributions of the population. Light may 
 be thrown upon this point by the experience of earlier years. From 1812 to 
 1815 there were 67 deaths recorded from whooping cough in an average popu¬ 
 lation of about 45,000, and on a basis of a case-fatality rate of 5 per cent (as 
 apparently obtained on an average between 1916 and 1920) there would have 
 been 1,340 cases, a total case incidence of about 3,000 per 100,000, or an aver¬ 
 age of 750 per 100,000 per annum. But in a single year, 1816, immediately 
 following this period, there were 105 deaths in a population of about 48,000, 
 which on the same ratio would mean 2,100 cases, or an incidence rate of 4,375 
 per 100,000. Accordingly, in the 5 years there would have been 3,440 cases, a 
 number equal to at least a fourth of the number of living children under 10 
 years of age in the population. Therefore, unless the disease was much more 
 common in the higher ages than has recently obtained, no such attack-rate 
 would have been likely. On the whole, therefore, it would appear that during 
 the 20-year period 1901-1920 the morbidity-rates were constantly rising and 
 the case-fatality rates were falling. 
 
 From the curves of the monthly annual mortality and morbidity rates (tables 
 65 and 67) it is evident that whooping-cough has, as a general rule, in¬ 
 creased in both mortality and in incidence in spring and early summer 
 months and often reaching, or at least maintaining, the highest levels in mid¬ 
 summer. The lowest rates have very commonly fallen in the late summer and 
 fall. Months in which the maximum mortality has occurred during the 65 
 years, 1856-1920, inclusive, as expressed in percentages of the total number of 
 years (table 68) were, August 23, July 17, September 14, January 9, February 
 and June, each, 8, March 6, April and October, each, 5, November 3, and May 
 and December, each, 2. Months of highest incidence, for the 24 years 1897- 
 1920, inclusive, similarly expressed (table 68), were, February 25, December 
 and July, each, 17, April, May, and August, each, 8, January, March, June, 
 and November, each, 4. On the same basis of calculation, months of lowest 
 incidence were, December 29, February and October, each, 17, March 13, May 
 and September, each, 8, January and July, each, 4. In no years did the highest 
 incidence fall in September or October, or the lowest incidence occur in April, 
 June, August, or November. 
 
 With the exception of such exclusion from school of children with whooping- 
 cough as may have been exercised by the school authorities, no administrative 
 measures were applied to restrict the spread of whooping-cough until 1916. 
 
 23 
 
Table 67 .—Mortality by months and years and monthly annual and annual mortality rates, per 100,000 living inhabitants, from whooping-cough, 
 
 from 1856 to 1920, inclusive. 
 
 4 
 
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350 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 Since this date recognized cases of the disease have been kept out of school, but 
 placarding houses with warning signs has been ineffective in keeping persons 
 out of infected households and patients from associating with other children on 
 the streets and elsewhere. 
 
 Table 68. —Maximum incidence oj mortality and maximum and minimum incidence of 
 morbidity from whooping-cough, by months, from 1856 to 1920, inclusive, and from 
 1897 to 1920, inclusive, respectively, and the percentage of each to total number of 
 years. 
 
 Months. 
 
 Months in 65 years 
 in which 
 
 maximum mortality- 
 rate obtains. 
 
 Months in 24 years 
 in which 
 
 maximum morbidity- 
 rate obtains. 
 
 Months in 24 years 
 in which 
 
 minimum morbidity- 
 rate obtains. 
 
 No. 
 
 Percentage to 
 total years. 
 
 No. 
 
 Percentage to 
 total years. 
 
 No. 
 
 Percentage to 
 total years. 
 
 Jan . 
 
 6 
 
 9 
 
 1 
 
 4 
 
 1 
 
 4 
 
 Feb . 
 
 5 
 
 8 
 
 6 
 
 25 
 
 4 
 
 17 
 
 Mar . 
 
 4 
 
 6 
 
 1 
 
 4 
 
 3 
 
 13 
 
 Apr. 
 
 3 
 
 5 
 
 2 
 
 8 
 
 • • • 
 
 • • • 
 
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 1 
 
 2 
 
 2 
 
 8 
 
 2 
 
 8 
 
 June . 
 
 5 
 
 8 
 
 1 
 
 4 
 
 • • • 
 
 • • • 
 
 J uly . 
 
 11 
 
 17 
 
 4 
 
 17 
 
 1 
 
 4 
 
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 15 
 
 23 
 
 2 
 
 8 
 
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 9 
 
 14 
 
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 2 
 
 8 
 
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 3 
 
 5 
 
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 4 
 
 17 
 
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 2 
 
 3 
 
 1 
 
 4 
 
 • • • 
 
 • • • 
 
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 2 
 
 4 
 
 17 
 
 7 
 
 29 
 
 Total . 
 
 65 
 
 100 
 
 24 
 
 100 
 
 24 
 
 100 
 
 DIPHTHERIA AND “ MEMBRANOUS ” OR TRUE CROUP. 
 
 Local chronicles are strangely silent on the subject of this ancient disease 
 described under many different names, which were gradually displaced by the 
 term diphtheria given it by Bretonneau in 1821. It is not known whether 
 the serious epidemic in New York City in the latter part of the eighteenth 
 century, described so well by Dr. Samuel Bard as angina suffocativa or sore- 
 throat distemper and later identified with diphtheria, reached Baltimore. 
 Croup and membranous croup were credited with a considerable number of 
 deaths in 1812 and each year thereafter until 1898. Charles Frick (4?) in 
 1855 included them among the “ zymotic 93 diseases. The term diphtheria did 
 not appear in the local statistical nosology until 1860, when it was credited 
 with 7 deaths, in contrast to 293 for membranous croup. By 1863 the propor¬ 
 tion was 162 to 294, in 1872 it was 100 to 162, and not until 1887 was it 
 the same. In the course of the next decade, croup or membranous croup gradu¬ 
 ally gave place in usage, and by 1898 it had become a subheading under 
 diphtheria. It will be noted that diphtheria did not appear in the causes of 
 death until two years after the beginning of the epidemic visitation in 1858. 
 The number of deaths ascribed to sore throat, cynanche tonsillaris, angina, 
 and inflammation of the throat was too small to have embraced deaths from 
 
FEBRILE DISEASES 
 
 351 
 
 typical faucial diphtheria if the latter had been at all frequent and fatal before 
 this date. 
 
 For any proper estimation of the real relation of true or membranous croup 
 to diphtheria in Baltimore, it is necessary briefly to review opinions held con¬ 
 cerning their identity during the period under consideration. Home (61), of 
 Edinburgh, who gave a good description of croup in 1765, regarded it as a 
 primary disease occurring independent of a previous angina. Bard (62), 
 writing in 1789, regarded croup and epidemic angina as the same disease. 
 Bretonneau, 1821, 1825, and 1826, was the first to recognize that the nasal, 
 faucial, laryngeal, ocular, cutaneous, and genital false-membranous lesions 
 were all manifestations of a specific local inflammation. His view of the identity 
 of croup and diphtheria was widely accepted, particularly in France. It was 
 disputed, however, especially in Germany, under the leadership of Virchow. 
 The great French clinician Trousseau, while in general agreeing with Breton- 
 neaffis views, impressed upon many his own opinion that diphtheria was a 
 general, and not primarily a local, affection. The correctness of Bretonneau’s 
 teachings were demonstrated finally by Boux and Yersin in 1888-1890, in 
 their experimental investigations on B. diphtheria described by Klebs in 1883 
 and cultivated by Loeffler in 1884. The mass of clinical and laboratory investi¬ 
 gations since the development of the antitoxin treatment in 1894 and of the 
 diphtheria culture test in 1896 have further confirmed them. 
 
 The manuscript lectures of William T. Howard, sr. (56), written about 
 1867 and illustrated with his views of personally observed cases, throw valuable 
 light upon the characteristics of membranous croup and diphtheria in Balti¬ 
 more and the views locally current concerning them at that time. His descrip¬ 
 tion of primary faucial diphtheria, with or without involvement of the nares, 
 larynx, conjunctiva, esophagus, skin, and genitals, was in general agreement 
 with those of Bretonneau and other French authors and of leading contempo¬ 
 rary writers of England, Hew York, and Philadelphia. However, on account of 
 the profound intoxication which characterized it, he, in opposition to Breton¬ 
 neau, held diphtheria to be primarily a general systemic disease, to which the 
 cyanosis, purpura, cardiac embarrassment, convulsions, coma, and paralysis, 
 as well as the swelling of the lymph-glands and the inflammatory processes of 
 the fauces, nares, larynx, esophagus, and other organs were all secondary. Of 
 croup he recognized three types: The spasmodic or false croup without false 
 membrane and rarely fatal, membranous or true croup, and diphtheritic croup. 
 The latter was regarded as a fortuitous complication of true diphtheria. Mem¬ 
 branous or true croup, though the false membrane in the larynx and certain 
 clinical symptoms were identical with those of diphtheritic croup, he held, 
 in opposition to the French writers, to be a separate and distinct disease. 
 Attacking young children and insidious in its onset and course, it was unat¬ 
 tended by high fever, prostration, and other symptoms of intoxication. Hoarse¬ 
 ness, gradual loss of voice, progressive difficulty in breathing, ending usually 
 in suffocation from mechanical closure of the larynx, were the cardinal symp¬ 
 toms. The mind was unaffected till near the end, and the coma, hemorrhages, 
 and swellings of cervical lymph-glands, so characteristic of diphtheria, were 
 absent. Nor did those who escaped death by suffocation develop paralysis, so 
 frequent in diphtheria. The inflammatory process did not, as was the case with 
 diphtheritic croup, involve other organs than the larynx. Membranous croup, 
 
352 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 unlike diphtheria, was a sporadic disease, never epidemic, and affected a 
 single child in a family or neighborhood. “ Until within a very few years past 
 (since 1858) no living American physician had seen a genuine widespread 
 epidemic of diphtheria, and yet all had ever been familiar with membranous 
 croup.” 
 
 This primary membranous croup was common enough, and unless trache¬ 
 otomy was performed was fatal in 90 per cent of the cases. Such, then, must 
 have been the characteristics of the membranous croup held responsible for 
 such high mortality from 1812 until long after 1870. In reply to the question, 
 was this diphtheria, it may be said that some years later (before 1880 at least), 
 with larger experience, Dr. Howard changed his opinion and taught that mem¬ 
 branous croup and diphtheritic croup were and had always been the same 
 disease, and that the confusion had been due to differences in the character of 
 diphtheria before and after the epidemic invasion of 1858. About 1885 it 
 became generally recognized in Baltimore that diphtheria might be primary in 
 the nose, throat, larynx, or elsewhere and remain confined to the original seat, 
 or descend or ascend as the case might be, and that contact with a case of 
 primary laryngeal diphtheria, or true croup, was often followed by the develop¬ 
 ment of faucial diphtheria in persons so exposed, and vice versa. Welch’s illu¬ 
 minating address on the causation of diphtheria before the Medical and Chi- 
 rurgical Faculty in 1891 dispelled lingering doubts in the minds of Baltimore 
 physicians and convinced them of the unity of faucial diphtheria and membra¬ 
 nous croup under the causal agency of B. diphtheria. 
 
 In the light of the foregoing considerations, it seems reasonably certain that 
 the deaths accredited to croup and membranous croup in the local statistical 
 nosology since 1812 belong to the category of laryngeal diphtheria, with or 
 without involvement of other structures, and that the whole number of deaths 
 assigned to this rubric and to diphtheria probably fall short of the whole 
 number. Some deaths due to diphtheria were probably classified under com¬ 
 plicating affections, and there was doubtless some confusion with scarlet fever, 
 particularly when the two diseases were at the height of their careers. 
 
 From table 60 and graph 17 the course of diphtheria, as determined by annual 
 mortality-rates, may be followed through 109 years. In the curve of mortality 
 as expressed in annual rates at least six separate and well-defined waves appear: 
 (1) 1812-1831, (2) 1832-1841, (3) 1842-1875, (4) 1876-1890, (5) 1891- 
 1893, (6) 1894-1908. Since the latter date the disease has, except for a sudden 
 rise in 1919, run a course fairly stable. During the first period, covering 19 
 years, the annual rates were relatively high, and in 4 years surpassed 100. 
 The second wave, extending over 10 years, was considerably lower, with 54 as 
 the highest annual rate. The third wave, covering 33 years, reached and main¬ 
 tained a relatively high level, with rates over 100 in 16 years and between 80 
 and 100 in 10 years. In the fourth wave, embracing 14 years, occurred the 
 highest annual rates attained, over 200 in 3 years (255 in 1881, 263, in 1882, 
 and 220 in 1883), and over 100 in 6 other years. In the fifth wave, covering 
 4 years, the highest rate was 97. The long final wave with its peak in 1898, 
 with a rate of 80, tailed off very gradually. Nearly all these waves are charac¬ 
 terized by minor elevations and depressions, which break the smoothness of their 
 curves. It will be noted that the third and longest wave had reached a relatively 
 high level (but no higher than the highest point attained by the first wave) 
 
FEBRILE DISEASES 
 
 353 
 
 before 1860, when the term diphtheria came into the statistical nosology. 
 However, as above indicated, during the years immediately following 1860, 
 a relatively large proportion of the deaths in this group were still classified 
 under croup. 
 
 Viewed from another angle, namely, by comparing the average annual death- 
 rates for 5-year periods from 1815 to 1920, it appears very clearly (table 61 
 and graph 18) that the period under observation begins with the end of the crest 
 of a long wave of relatively high mortality, only 9 years of which, 1812-1820, 
 come under view, with a sharp decline during the next 10 years, 1820-1830. 
 From this point begins the second wave the whole extent of which is in view. 
 Rising very gradually between 1835 and 1840, and remaining stationary during 
 the next 5 years, the ascent is first rapid and then again gradual to a peak 
 reached in 1861-1865. From this, after a second recession occupying a 10-year 
 period, the ascent is resumed to a second peak in 1881-1885. The 5-year period 
 ending in 1885 marks the acme; never before was its lethal power so great. 
 During the following 5 years there is an abrupt decline from 195 to 67, a point 
 maintained with but slight variation for 10 years, 1890-1900. The mortality- 
 rates as averaged for 10-year periods (table 61, graph 19) fell continuously 
 and sharply from 91 in 1812-1820 to 39 in 1830-1840. During the succeeding 
 30 years they ascended steadily and by equal steps to a peak with a rate of 136 
 in 1860-1870. Falling slightly in the next 10-year period, the rates had reached 
 131 by 1880-1890. From this point they fell precipitately to 68 in 1890-1900, 
 or to about the level attained in 1840-1850. This remarkable tidal-wave of 
 mortality rose through a period of 30 years to a crest, which, though broken 
 was held for 20 }^ears and then fell in 10 years by two-thirds of its rise. The 
 descent in the rates during the 20-year period after 1901, to the low level of 13 
 occurred under altered conditions. Since, as will be shown later, almost the 
 whole of the mortality from diphtheria occurs in individuals under the tenth 
 year, rates specific for this age-group for the census years 1830 to 1920, inclu¬ 
 sive, which are presented in table 64 may be studied with profit. While the 
 rates for these selected years represent, for the most part, by no means the 
 peak-rates of the corresponding periods, they illustrate fairly accurately the 
 rise in mortality from about 1850 to the climax in the ninth decade of the 
 last century, the subsequent gradual decline in the preantitoxin days and the 
 conspicuous drop after 1900. It is evident that changes in the proportion of 
 this age-group in the population in the last 20 years has been too slight to 
 have exerted any important influence upon this decline. 
 
 In spite of the evidence that diphtheria never appeared in epidemic outbreaks 
 in Baltimore before 1858 and that in its prevalent form as membranous croup 
 up to that date it appeared only sporadically and was not evidently spread from 
 one person to another by personal contact, it was nevertheless responsible for 
 relatively high death-rates between 1812 and 1823 and between 1847 and 1858. 
 Indeed, it was only between 1859 and 1868 and between 1877 and 1883 that 
 the rates conspicuously surpassed those that often obtained before 1858. 
 
 The data from which morbidity and case fatality in diphtheria may be 
 studied date from 1893, the year in which the mortality-rate fell to the lowest 
 level since 1881. Since in this and the 3 succeeding years the cases were 
 reported so inadequately and their monthly distribution was not recorded, the 
 reported cases for this period have not been included in the regular tables. 
 
354 PUBLIC HEALTH ADMINISTRATION - , ETC., IN BALTIMORE 
 
 For these 4 years the absolute and relative figures for mortality and case 
 fatality were as presented in table 69. 
 
 From these figures with continuously rising morbidity-rates (and except in 
 1896 rising mortality-rates also), which were considerably lower than ever again 
 achieved (except in 1909 and 1910) and associated with steadily falling case- 
 fatality rates, it is clear that comparison with later years is not warranted. 
 In the first two of these years antitoxin was not available, and during the last 
 two it could not have been very widely used. It is particularly to be noted that 
 the above case-fatality rates can not with justice be taken as criteria for com¬ 
 parison with rates during the antitoxin period. 
 
 Table 69. 
 
 Year. 
 
 Cases. 
 
 Morbidity-rate 
 per 100,000. 
 
 Deaths. 
 
 Per cent 
 case 
 fatality. 
 
 1893 .... 
 
 346 
 
 76 
 
 210 
 
 60.7 
 
 1894 .... 
 
 409 
 
 88 
 
 231 
 
 56.5 
 
 1895 .... 
 
 629 
 
 133 
 
 310 
 
 49.3 
 
 1896 .... 
 
 653 
 
 136 
 
 280 
 
 42.9 
 
 Turning to tables 70 and 71, it will be observed that there is a close corre¬ 
 spondence between the course of the curves for mortality and morbidity since 
 1897. After a steady fall in both until 1910, they were subject to an upward 
 wave during the next 3 years, from which there was a descent to the lowest 
 points reached in the former in 1918 and in the latter in 1917. They rose 
 together and markedly in 1919 and descended in 1920. From this close corre¬ 
 spondence it would appear that the cases during this time have been reported 
 with a fair degree of accuracy and evenness, and that the courses of morbidity 
 and mortality must have been influenced by causes acting at the same time 
 and on the whole with very much the same degree of force. 
 
 It is evident that the medical and administrative agencies that have tended 
 to reduce the death-rate (more accurate and earlier diagnosis, antitoxin treat¬ 
 ment, and the extension of the use of intubation) have not seriously influenced 
 case incidence; for every case saved from death, until the augmentation of the 
 restrictive measures after 1910, and especially after 1915, meant a potential 
 carrier to spread the disease and thus to increase the incidence rate. While there 
 was a considerable fall in incidence in 1916, 1917, and 1918, after the imposi¬ 
 tion of much more restrictive measures than had before obtained, with special 
 emphasis on the use of the culture method to govern the control of convalescents 
 and carriers, the morbidity-rates surpassed those of 1913, 1914, and 1915. 
 As a matter of fact, the average morbidity rate for the 5-year period ending 
 in 1920 is scarcely lower than that ending in 1910, 156 and 159, respectively. 
 
 From the average morbidity-rates for the 5-year periods (table 71) it is 
 clear that, on the whole, the more intensive efforts to curtail diphtheria during 
 the last 5 years were associated with results no better than during the 5 years 
 ending in 1910. In so far as these data justify conclusions, it may be said that 
 under the conditions obtaining in Baltimore the invasive capacity of diph¬ 
 theria is inconstant, that the course of morbidity preserves its tendency to run 
 
FEBRILE DISEASES 
 
 355 
 
 in waves, and that restrictive measures as applied exert, on the whole, but 
 comparatively little influence upon the relative incidence of the disease over a 
 considerable term of years. In 1919 and 1920 the incidence of the disease 
 relative to the population was very much the same as in 1901, 1913, and 1914. 
 It may be argued, perhaps with justice, that the waves noted would have reached 
 higher levels but for the interferences interposed by publicly and privately 
 directed activities. So far as may be judged from the experiences of 1921, 
 the only year for which the necessary data are available, morbidity from diph¬ 
 theria has been profoundly influenced by age, color, and sex. Rates specific for 
 these categories for this year are given in table GO. While the disease occurred 
 in every decade of life up to the ninth, approximately three-fourths of the 
 cases were in individuals under the tenth year of age. Considering this age- 
 group first, it will be noted that the rates were higher in the first than in the 
 second 5 years of life and that the incidence was particularly high in the first 
 year. From the tenth year on, the rate of incidence decreased through the 
 decades in regular order, with the exception that the rate was higher in the 
 eighth than in the seventh. In respect of race, all cases in individuals over the 
 thirty-ninth year of age were in whites and in every age-group below this 
 period of life, with the exception of the first year, the attack rate was markedly 
 higher in whites than in negroes. While, on the whole, in the first two decades 
 of life the incidence was greater in males than in females in both races, the 
 reverse was true from the third to the seventh decade, inclusive. This change 
 in order of incidence is perhaps due, in some degree at least, to the greater 
 facilities falling to the lot of women in household life for contact with cases of 
 the disease. 
 
 The effect of season upon the incidence and mortality of diphtheria is very 
 distinct. From the curve of the monthly annual mortality-rates (table 70) it is 
 clear that the highest fatality has commonly occurred in the fall and early 
 winter and the lowest fatality almost always in the warmer months. In typical 
 years, from its low point in the summer, the mortality-rate rises considerably 
 and often abruptly in September and continues to ascend through the fall 
 months to a peak in December or January, from which the decline is gradual, 
 though often irregular, to the low point in midsummer. Months of maximum 
 mortality, between 1856 and 1920, as expressed in percentages of the total 
 number of years (table 72) were: December 28, January 25, November 22, 
 October 15, February 9, and March 2. Months of minimum mortality similarly 
 expressed were: July 38, August 18, June 17, May 14, April 8, September 3, 
 and November 2. The highest rates never occurred between April and Septem¬ 
 ber, inclusive, and with the exception of one year, the lowest incidence fell 
 within these months. 
 
 The relation between season and the incidence of diphtheria is shown even 
 more accurately in the monthly annual morbidity-rates (table 71) for the 24 
 years, 1897-1920. The curves of the morbidity and mortality rates for these 
 years follow the same trend, the latter lagging, as is to be expected, about a 
 month behind the former. Months of maximum incidence, as expressed in 
 percentages of occurrence in these 24 years (table 72), were: November 38, 
 December 33, January 17, October 8, and February 4. As determined on the 
 same basis, months of minimum incidence were: July 50, June and August, 
 
356 
 
 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
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FEBRILE DISEASES 
 
 359 
 
 each 21, and May 8. September, March, and April were never months of either 
 maximum or minimum incidence. 
 
 Owing to the incompleteness of case reporting, it is manifestly impracticable 
 to calculate with any accuracy a normal diphtheria case-fatality rate for Balti¬ 
 more during the preantitoxin days. In 1895 and 1896 antitoxin was used to 
 some extent; but if, for the sake of establishing a standard somewhat arbitrary, 
 1896 be taken as a representative year, and the favorable influence of the anti¬ 
 toxin used on those able to pay for it and willing to waive prejudice against 
 the new remedy be considered as offsetting the defectiveness of case reporting, 
 the normal diphtheria case-fatality rate without antitoxin treatment would be 
 42.9 per cent. The much lower case-fatality rate in 1897 (22.2 per cent) when 
 antitoxin was first freely distributed and therefore fairly widely used, may then 
 
 Table 72 .—Maximum and minimum incidence of mortality and morbidity from diph¬ 
 theria by months, from 1856 to 1920, inclusive, and from 1897 to 1920, inclusive, re¬ 
 spectively, and the percentage of each to the total number of years. 
 
 Months. 
 
 Months in 65 years in 
 which maximum 
 mortality-rate 
 obtains. 
 
 Months in 65 years in 
 which minimum 
 mortality-rate 
 obtains. 
 
 Months in 24 years in 
 which maximum 
 morbidity-rate 
 obtains. 
 
 Months in 24 years in 
 which minimum 
 morbidity-rate 
 obtains. 
 
 No. 
 
 Percentage to 
 total years. 
 
 No. 
 
 Percentage to 
 total years. 
 
 No. 
 
 Percentage to 
 total years. 
 
 No. 
 
 Percentage to 
 total years. 
 
 Jan. 
 
 16 
 
 25 
 
 • • • 
 
 • • • 
 
 4 
 
 17 
 
 • • • 
 
 • • • 
 
 Feb. 
 
 6 
 
 9 
 
 • • • 
 
 • • • 
 
 1 
 
 4 
 
 • • • 
 
 • • • 
 
 Mar. 
 
 1 
 
 2 
 
 • • • 
 
 • • • 
 
 
 
 • • • 
 
 • • • 
 
 Apr. 
 
 
 
 5 
 
 8 
 
 
 
 • ♦ • 
 
 • • • 
 
 May . 
 
 
 
 9 
 
 14 
 
 
 
 2 
 
 8 
 
 June . 
 
 
 
 11 
 
 17 
 
 
 
 5 
 
 21 
 
 July . 
 
 
 
 25 
 
 38 
 
 
 
 12 
 
 50 
 
 Aug. 
 
 
 
 12 
 
 18 
 
 
 
 5 
 
 21 
 
 Sept. 
 
 
 
 2 
 
 3 
 
 
 
 • • • 
 
 • • • 
 
 Oct. 
 
 10 
 
 15 
 
 • • • 
 
 • • • 
 
 2 
 
 8 
 
 • • • 
 
 • • • 
 
 Nov. 
 
 14 
 
 22 
 
 1 
 
 2 
 
 9 
 
 38 
 
 • • • 
 
 • • • 
 
 Dec. 
 
 18 
 
 28 
 
 • • • 
 
 • • • 
 
 8 
 
 33 
 
 • • • 
 
 • • • 
 
 Total .. 
 
 65 
 
 100 
 
 65 
 
 100 
 
 24 
 
 100 
 
 24 
 
 100 
 
 be taken as an index, admittedly only approximate, of the curative value of 
 antitoxin as then used and of its immediate actual influence upon mortality in 
 this disease. In this year, as compared with 1896, while the morbidity-rate 
 increased by 140 per cent, the mortality-rate increased by only 25 per cent, and 
 the case-fatality rate fell by 48 per cent. The case-fatality rate fell by very 
 gradual steps in the face of continually improved case reporting during the 
 next 7 years and reached the low point of 9 per cent in 1904. The lowest point 
 attained was 6.2 per cent in 1913. During the first 4 years during which anti¬ 
 toxin was freely used, 1897-1900, the average case-fatality rate was 18.5 per 
 cent, and the average rates for 5-year periods from 1901 to 1920 were 11.7, 8.9, 
 7.1 and 8.6 per cent. It will be noted that unless it be assumed, and for this 
 there is no warrant, that case reporting has become much more accurate in 
 the last 5 years, the treatment of diphtheria and the management of diphtheria 
 cases in Baltimore reached its high point of efficiency by 1915, and during the 
 last quinquennium ground has actually been lost. It is of interest that, while 
 
360 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 the trend of the curve of the case-fatality rate follows very closely those of both 
 morbidity and mortality until 1909, since this date the agreement in trend has 
 been almost completely lost so far as concerns morbidity and very much modi¬ 
 fied as concerns mortality. 
 
 In recent years, the mortality from nasal and faucial diphtheria, uncompli¬ 
 cated by laryngeal involvement, has been comparatively small. Of the total 
 number of 248 deaths ascribed to diphtheria in 1919 and 1920, Dr. John F. 
 Hogan found on personal inquiry of the attending physicians that 203, or 82 
 per cent, had laryngeal diphtheria, and that in 45 or 18 per cent the disease 
 did not involve the larynx. For the two years the average mortality-rates were 
 20 and 14, respectively. 
 
 Of the 3,184 deaths credited according to the loose classification of those 
 times to croup and to diphtheria together in the 10-year period 1863-1872, 
 2,258 or 70 per cent were apportioned to the former and 952 or 30 per cent to 
 the latter. If it be justifiable to assume that in this series deaths assigned to 
 croup represented laryngeal diphtheria and those ascribed to diphtheria repre¬ 
 sented faucial and nasal diphtheria without laryngeal involvement, it would 
 appear that antitoxin treatment has exercised a less striking influence upon the 
 relative fatality of these two anatomical forms of diphtheria than is commonly 
 supposed. Unfortunately, for neither of these groups are data available as to 
 the relative morbidity of laryngeal and faucial diphtheria. 
 
 The influence of sex and color also upon mortality was signifiant for the 15- 
 3 *ear period, 1906-1920, for which specific data are available. The 1,221 deaths 
 during this period were distributed by sex and color as follows: White 1,129, 
 negro 92, white males, 576, white females 553, negro males 47, negro females 45. 
 The deaths among whites and negroes were in the ratio of 12 to 1, while the 
 proportion of whites to negroes in the population was on the average 5.42 to 1; 
 i. e., diphtheria was more than twice as fatal for whites as for negroes. In both 
 races the fatality was distinctly higher in males than in females. This is greatly 
 at variance with the experience for 1850, when, according to Frick, the mortality 
 per 10,000 from croup was 8.5 in whites and 8.8 in negroes, and of the whole 
 number of deaths for both races 49 per cent were in males and 51 per cent 
 in females. 
 
 In tables 62 and 63 death-rates by age, color, and sex are given for the 
 census years 1910 and 1920. No deaths occurred in individuals over the fortieth 
 year, nearly the whole mortality fell within age-period 0 to 9 years, and over 
 three-fourths of it below the fifth year of life. Of the 142 deaths from croup in 
 1850 analyzed by Frick (table 73), 134, or 94 per cent, were under 5 years of 
 age. In both 1910 and 1920 the rates were much higher in whites than in 
 negroes. In 1910 mortality was greater in males than in females in both races, 
 and in 1920 in females than in males among whites and in males than in females 
 among negroes. 
 
 Up to about 1900 the whole course of diphtheria in Baltimore may be regarded 
 as natural and practically uninfluenced by artificial interferences, for certainly 
 before 1898 no measures of a restrictive kind, which may by any stretch of 
 the imagination be considered effective, were directed against the disease by the 
 health department. And no one who has read the text-book directions or sug¬ 
 gestions for the treatment of diphtheria or who has seen them applied will con¬ 
 tend that, before the general use of the O’Dyer intubation method and of anti- 
 
FEBRILE DISEASES 
 
 361 
 
 toxin during the late years of the nineteenth century, physicians, on the whole, 
 saved more diphtheria patients than they killed. What influence immigration 
 exerted upon the course of diphtheria in Baltimore it is impossible to say. 
 The coincidence of the rise in the second wave with the large foreign migration 
 starting in the fifth decade of the nineteenth century and of its fall with decrease 
 in migration in its latter years may be significant. At any rate, it is not unlikely 
 that the decline in the death-rate between 1820 and 1830 represented a true 
 decrease in virulence of the type of diphtheria then locally prevalent, and that 
 the second wave was associated, in part at least, with importation of the disease 
 in more potent form from Europe during the exacerbation of the disease about 
 the middle of the century. It is of considerable interest, in connection with 
 the second wave, that during the 35 years, 1840-1875, marking its first phase, 
 the average annual death-rate from diphtheria was 100, and during the 25 years 
 of its second phase, 1875-1900, it was 107. 
 
 Table 73 .—Number of deaths and rate of death, per 100,000 
 living inhabitants, from croup, according to age, for 1850. 
 Calculated from figures given in Frick’s tables. 
 
 Age-period. 
 
 Croup. 
 
 Deaths. 
 
 Rate. 
 
 Under 1 year.. 
 
 54 
 
 881 
 
 I to 4 years. 
 
 80 
 
 434 
 
 5 to 9 years. 
 
 8 
 
 40 
 
 Under 10 years. 
 
 142 
 
 318 
 
 10 to 19 years. 
 
 
 
 20 to 29 years. 
 
 
 
 30 to 39 years. 
 
 
 
 40 to 49 years. 
 
 
 
 50 to 59 years. 
 
 
 
 60 years and over. 
 
 
 
 Total . 
 
 142 
 
 84 
 
 For this period there exist no data for morbidity-rates. Viewed from the 
 annual mortality-rates, the curve of diphtheria mortality reached its highest 
 point in 1882. From this date the fall in the death-rate was continuous to 1908, 
 except for comparatively minor rises covering the years 1890-1892 and 1894- 
 1900. These minor waves, to which attention has already been directed, did not 
 approach, however, the immediately previous high level. It is to be noted that 
 the highest point of this second minor wave, considerably lower than that of 
 the one of 1890-1892, was in 1899. These two breaks in the curve of descent in 
 the diphtheria mortality-rate may be regarded as reactions from a rather sudden 
 fall and as an indication of a tendency of the disease to reach an equilibrium 
 and a death-rate of between 60 and 70. On the other hand, as the artificial 
 interferences, begun in 1897 and 1898, which will be more fully explained 
 later, could not have offered any decided and compelling resistance until several 
 years later, it is not unlikely that under natural conditions a much lower rate 
 than 49 reached in 1889 might have been attained and the point of equilibrium 
 established for a period at least around a rate of 40 or even lower, as obtained 
 for the 20 years between 1826 and 1845. 
 
362 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 It is interesting to note that in 1883 a high rate was recorded for scarlet 
 fever, and that the rates for these two diseases fell simultaneously, though the 
 descent in diphtheria was much less rapid and striking than in scarlet fever. 
 
 The development and application of restrictive measures against the spread 
 of diphtheria were very gradual. As previously pointed out, though mem¬ 
 branous croup was made reportable in 1882 and diphtheria in 1894, reports 
 were not made at all until 1893, and not with any completeness until 1898 
 or 1900. 
 
 Though the bacteriological laboratory was available for diagnosis, and anti¬ 
 toxin was obtainable for protection and treatment in 1896 and 1897, it was 
 some years before they were very generally used. It was not until 1898 that 
 warning signs were posted on dwellings and institutions harboring diphtheria 
 cases, that isolation of diphtheria patients was seriously attempted, that a nega¬ 
 tive throat-culture (taken by the attending physician or by the single throat 
 inspector appointed this year) was required from the patient and household con¬ 
 tacts before disinfection and release, and that children were not allowed to 
 return to public schools without a certificate of recovery. During this same year 
 there was instituted semi-weekly notification to each public school of the names 
 and addresses of any pupils sick with diphtheria and scarlet fever. In 1900 a 
 second throat inspector was appointed to make cultures for release of diphtheria 
 convalescents. 
 
 Precautions against spread of the disease through contacts and carriers, by 
 means of milk and other foods, and the control of milk and cream from farms 
 and dairies exposed to known cases and contacts were not routinely undertaken, 
 with any completeness at least, until after 1912. As late as 1910, in only 395 
 of the 793 cases of diphtheria reported was the diagnosis confirmed by culture, 
 and of the 3,401 cultures for discharge taken by the throat inspectors and 
 private physicians from convalescents and from contacts, only 289 were positive. 
 The next year the throat inspectors began taking nasal as well as faucial 
 cultures, but only one negative culture from each situation was required, and 
 if either throat or nose culture were found negative on one occasion it was 
 counted as permanently negative and future cultures were confined to the organ 
 found positive. When diphtheria broke out in institutions, cultures were made 
 from all the inmates, the carriers were isolated in a group, and those who were 
 found negative on a single culture-test were discharged. In St. Vincent’s 
 Orphan Asylum, with its large population of sucklings and older children, in 
 connection with these imperfect measures and the total lack of rooms for iso¬ 
 lation of incoming as well as permanent inmates, diphtheria continued endemic. 
 
 In December 1915 these regulations and practices were so amplified that two 
 consecutive negative cultures taken at intervals of at least 48 hours from 
 both nose and throat were required before release of convalescents and contacts; 
 all contacts and reported cases were submitted to culture; all carriers and all 
 attendants, whether proven carriers or not, were isolated; and other members 
 of households with diphtheria cases after two negative nose and throat cultures 
 were allowed to mix with the public at will, if the isolation of the patient and 
 any carriers in the households was complete, or on change of domicile. In the 
 case of both convalescents and healthy carriers, virulence tests were made after 
 the twenty-eighth day, and if their cultures proved non-virulent for guinea- 
 pigs they were released. Within the next 2 years hospitals and institutions 
 
FEBRILE DISEASES 
 
 3G3 
 
 receiving children were required, except in emergencies, to make cultures of 
 prospective inmates before admission and to establish suitable isolation quarters 
 for diphtheria cases and carriers or to send them to Sydenham Hospital. All 
 cultures for discharge were required to be taken by representatives of the 
 health department. Members of the classes of school-children developing diph¬ 
 theria were cultured and those found to be diphtheria carriers excluded. 
 
 These procedures, with strict supervision of the disinfection of all milk 
 utensils before returning to dairymen, enormously increased the work of the 
 health department in connection with diphtheria. The work of the bacteriologi¬ 
 cal laboratory was greatly augmented—from an average of 80 to 90 diphtheria 
 cultures on an average day in the winter to 400. In 1920 there were 62,644 
 cultures examined, 14,037 from inmates of institutions and 48,607 from house¬ 
 holds or schools; of the latter number, 3,848 were submitted for diagnosis, 
 17,992 were from contacts, and 26,767 were for discharge of convalescents or 
 contactive carriers, an average of over 160 diphtheria cultures every day in 
 the year. 
 
 In the meantime, since 1910 an increasing number, but never any consider¬ 
 able moiety of the total number of cases of diphtheria, and some chronic 
 carriers, were treated at Sydenham Hospital. This hospital, though incon¬ 
 veniently situated, faulty in design, and inadequately equipped, managed diph¬ 
 theria cases in a manner wholly creditable until the depletion of its personnel 
 during the war, and, while it can not have exerted any considerable influence 
 upon restricting morbidity, it has undeniably been responsible for influencing 
 favorably the mortality from this disease. Its chief service in this regard has 
 been rendered in the intelligent care of cases of laryngeal diphtheria, many of 
 which, however, have reached it too late to be saved by intubation, antitoxin, 
 and nursing. Its clientele in this group of cases has been drawn largely from 
 the poor and ignorant and often referred when in articulo mortis by physicians 
 called after the disease was far advanced. 
 
 ACUTE INFLAMMATORY AFFECTIONS OF THE LUNGS AND PLEURA; I. E., 
 
 BRONCHITIS, PNEUMONIA, AND PLEURISY. 
 
 The affections here considered are grouped upon a purely anatomical basis, 
 and the only member of the group, croupous or lobar pneumonia, for which the 
 evidence at hand indicates the action of a specific cause, is, certainly during 
 most and probably during all of the period for which records exist, so hopelessly 
 intermixed and confused in the nosological classification that it is not possible 
 to separate it out with any reasonable degree of accuracy. Pleurisy is so evi¬ 
 dently bound up with pneumonia that even in later years it can not certainly 
 be set up as a separate category. Deaths listed under bronchitis undoubtedly 
 included many due to pneumonia, and only recently was there a distinction 
 made between acute and chronic bronchitis. In table 60, the categories to which 
 deaths under these various groupings were assigned are arranged in chronologi¬ 
 cal order. It will be noted that pleurisy alone appeared before 1818, played the 
 leading role until 1822, and continued to be a serious rival of the other cate¬ 
 gories for many years later. Inflammation of the lungs made its appearance 
 with credit for a relatively considerable number of deaths in 1818, then in a 
 few years receded to an inconspicuous position, and did not become important 
 24 
 
364 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 again until about 1850. It almost entirely disappeared after 1874. Pneumonia 
 first appeared in the nosological classification in 1821, with a few deaths for 
 2 years; in 1823 it rivaled pleurisy and surpassed inflammation of the lungs 
 and then practically disappeared, except for the 6 years between 1845 and 1850, 
 until 1875, when it became the one prominent cause of death in this whole 
 group. In the meantime, catarrhal fever, which in 1855 Frick held to be infan¬ 
 tile pneumonia and bronchitis, appeared in 1823, and soon began to equal and 
 then to surpass in numbers, first, any other, and then, about 1840, all other cate¬ 
 gories of this group. As late as 1898 a few deaths were ascribed to catarrhal 
 fever. Broncho-pneumonia appeared in the nosology in 1879 with 4 deaths. 
 The proportion of deaths classified under this heading increased very gradually, 
 and finally by 1920 nearly half of the total number of deaths credited to pneu¬ 
 monia were classed under this heading. 
 
 Bronchitis appeared as a separate disease in 1841 (with 5 deaths), but was 
 not ascribed any considerable number of deaths (46) until 1872. It lapsed 
 completely in 1875 and appeared only once again, in 1898. It was supplanted 
 by inflammation of the bronchi, to which an increasingly large number of 
 deaths was credited until it in turn sank into oblivion in 1898. Capillary bron¬ 
 chitis appeared as a cause of death from 1878 until 1900. The terms “ acute ” 
 and “ chronic 99 bronchitis, introduced with the adoption of the international 
 classification in 1899, have shared with each other all the deaths credited to 
 bronchitis since that date. 
 
 From this rapid review it is clear that by no method of arrangement can the 
 figures under these various categories be so grouped as to indicate with any 
 reasonable degree of definitiveness the true proportion of deaths ascribable to 
 acute or chronic bronchitis, or to broncho and lobar pneumonia, or to primary 
 pleurisy. In the early days pleurisy must have included not only all forms of 
 acute pneumonia, but some deaths from phthisis, chronic cardiac disease, and 
 the like. Pneumonia, catarrhal fever, and inflammation of the lungs must have 
 included some deaths of persons with bronchitis, acute and chronic, as well as 
 deaths of individuals with various other acute and chronic diseases that would 
 now be otherwise classified. Catarrhal fever and capillary bronchitis, synonyms 
 for catarrhal pneumonia, properly belonged and, since 1900, have fallen 
 to broncho-pneumonia. It is probable that in most if not all the fatalities 
 ascribed to acute bronchitis the inflammatory process also involves the lung, 
 and that this term as used signifies pneumonia, usually broncho-pneumonia. 
 Particularly in the light of the experience of MacCallum and of other pathologi¬ 
 cal anatomists, studying the abundant army material in the late war, it is 
 very improbable that much dependence can be placed upon the diagnosis of 
 broncho-pneumonia as distinguished from lobar pneumonia, in at least a very 
 large proportion of instances as certified upon death certificates without post¬ 
 mortem examination. Chronic bronchitis, to which some deaths continue to 
 be ascribed to the end of the period, can not be separated from acute bronchitis 
 before 1899, and is therefore included with acute bronchitis to avoid an incon¬ 
 sistency even greater were it omitted. 
 
 From these observations and explanations it would appear that rates calcu¬ 
 lated for any single one of the above categories would be without value; that 
 rates calculated on the basis of the sums of the categories as arranged under 
 bronchitis, or under pneumonia and pleurisy, can have no definitely significant 
 
FEBRILE DISEASES 
 
 365 
 
 value; and that rates calculated on the basis of the sum of the deaths under all 
 the categories relating to bronchitis, pneumonia, and pleurisy are relatively 
 significant, but subject, of course, to uncertain errors due to idiosyncrasies of 
 classification, to errors of diagnosis, and to the custom only in recent years 
 successfully overcome of ascribing to bronchitis and pneumonia deaths of 
 individuals with various acute and chronic diseases in which pulmonary com¬ 
 plications are secondary. 
 
 Despite the numerous faults of classification above pointed out, it is evident 
 from table 60, graph 17 (in which are given separately rates calculated for 
 bronchitis, pneumonia, and the total of the two), that the acute pulmonic 
 diseases were well established as important causes of death early in the nine¬ 
 teenth century. Taken together, they started with a death-rate of 139 in 1812 
 and in 1814 attained a rate (246) not surpassed until 1890-1896, and in 9 
 other years subsequent to the latter date. It was not until 1874 that bronchitis, 
 introduced into the statistical nosology in 1841, began to rank significantly; and 
 since 1904 its importance has gradually declined until by 1919 it had again 
 become an insignificant factor. It will be noted that, while coincident with the 
 rise here in the curve for bronchitis and a slight corresponding fall in the curve 
 for pneumonia, the curve for the combined rate is not dependent upon the 
 introduction of a new factor. On the whole, it seems improbable that the differ¬ 
 entiation of bronchitis into separate statistical rubrics really increased in any 
 considerable degree the number of deaths that otherwise would have been 
 credited to acute pulmonic disease and thereby actually increased the rate. 
 
 In the course of the curve of the rate for the combined group of acute pul¬ 
 monic diseases there are several noticeable waves. The first wave, covering a 
 period of 20 years, began in 1812, reached its high point in 1814, with a rate 
 of 246, and gradually subsided, after considerable fluctuations toward the end 
 of the period, to a rate of 70 in 1831. The second wave, 1832—1840, reached its 
 high point of 160 in 1835 and its low point of 83 in 1840. The third wave, 
 1841-1865, was marked by several minor waves. The highest rates attained 
 were 170 in 1848 and 206 in 1852. A fourth wave reached a peak in 1872 with 
 a rate of 222 and gradually descended to 150 in 1878. The next year the rate 
 rose and maintained a rather constant level of about 200 until 1889. In this 
 and the next year rates of 308 and 315 were reached and between 1892 and 1899 
 the annual rates varied between 224 and 290. After a rise to 317 in 1900, the 
 rate fell to 203 in 1908. With minor fluctuations, the annual rate hovered 
 around 225 until 1915; it began to rise in 1916, and, in the influenza year 1918, 
 reached 607. During the next 2 years it fell to about 200. It will be noted that 
 since about 1830 the rate for the acute pulmonic diseases has been rising. 
 
 The curve of the rates averaged for 5-year periods (table 61, graph 18) fell 
 abruptly from a high point in 1812-1815 to 75 in 1821-1825; from this it 
 ascended by gradual steps to a rate of 165 reached in 1851-1855. A drop 
 during the next 10 years to 97 w r as followed by another gradual ascent to an 
 average rate of 277 in 1891-1895. Following a graduated decline, a rate of 222 
 was reached in 1911-1915, and from this there was a jump to 305 in 1916-1920. 
 
 With the annual mortality rates averaged for 10-year periods (table 61, 
 graph 19), from a peak of 159 in 1812-1820, the rates fell abruptly to 77 in 
 1821-1830. The peak of a second "wave was attained in 1851-1860, with a rate 
 
366 
 
 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 of 149. After a moderate drop to 122 in 1861-1870, the rate rose steadily to 272 
 in 1891-1900. Following a slight recession to 243 in 1901-1910, the rate rose 
 to 264 in 1911-1920. 
 
 A straight line fitted to the curve of rates averaged by 5- and 10-year periods, 
 from 1825 to 1920, would follow a progressively increasing death-rate from the 
 pulmonic diseases during a period covering 95 years. The full significance of 
 this fact and of the fall culminating in 1825 will be discussed in another 
 section. 
 
 The absolute figures for deaths and the death-rates for broncho and lobar 
 pneumonia from 1906 to 1920, and for bronchitis from 1905 to 1915, both for 
 sex and color, are set forth in table 74. The lessons to be drawn from the curves 
 
 Table 74. — Number of deaths and rate of death, per 100,000 living inhabitants, from 
 pneumonia and bronchitis, according to color and sex, from 1905 to 1920, inclusive * 
 
 D = death. It = rate. 
 
 TOTAL PNEUMONIA. 
 
 Year. 
 
 White. 
 
 Colored. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 1905 . 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1906 . 
 
 650 
 
 141 
 
 329 
 
 146 
 
 321 
 
 136 
 
 372 
 
 438 
 
 206 
 
 539 
 
 166 
 
 351 
 
 1907 . 
 
 685 
 
 147 
 
 376 
 
 165 
 
 309 
 
 129 
 
 409 
 
 475 
 
 224 
 
 577 
 
 185 
 
 391 
 
 1908 . 
 
 583 
 
 123 
 
 293 
 
 127 
 
 290 
 
 120 
 
 357 
 
 409 
 
 185 
 
 469 
 
 172 
 
 359 
 
 1909 . 
 
 723 
 
 151 
 
 366 
 
 157 
 
 357 
 
 146 
 
 392 
 
 443 
 
 204 
 
 510 
 
 188 
 
 388 
 
 1910 . 
 
 770 
 
 160 
 
 395 
 
 167 
 
 375 
 
 152 
 
 289 
 
 322 
 
 160 
 
 394 
 
 129 
 
 263 
 
 1911 . 
 
 733 
 
 150 
 
 378 
 
 158 
 
 355 
 
 143 
 
 381 
 
 419 
 
 211 
 
 512 
 
 170 
 
 342 
 
 1912 . 
 
 687 
 
 140 
 
 349 
 
 144 
 
 338 
 
 135 
 
 361 
 
 392 
 
 199 
 
 476 
 
 162 
 
 322 
 
 1913 . 
 
 797 
 
 160 
 
 417 
 
 171 
 
 380 
 
 151 
 
 401 
 
 430 
 
 212 
 
 500 
 
 189 
 
 372 
 
 1914 . 
 
 834 
 
 166 
 
 442 
 
 179 
 
 392 
 
 154 
 
 367 
 
 389 
 
 204 
 
 475 
 
 163 
 
 317 
 
 1915 . 
 
 768 
 
 152 
 
 399 
 
 160 
 
 369 
 
 144 
 
 364 
 
 381 
 
 200 
 
 459 
 
 164 
 
 315 
 
 1916 . 
 
 947 
 
 186 
 
 503 
 
 200 
 
 444 
 
 172 
 
 455 
 
 470 
 
 242 
 
 548 
 
 213 
 
 405 
 
 1917 . 
 
 907 
 
 176 
 
 521 
 
 205 
 
 386 
 
 148 
 
 554 
 
 566 
 
 322 
 
 720 
 
 232 
 
 437 
 
 1918 . 
 
 2697 
 
 520 
 
 1538 
 
 599 
 
 1159 
 
 443 
 
 830 
 
 838 
 
 428 
 
 944 
 
 402 
 
 749 
 
 1919 . 
 
 962 
 
 156 
 
 518 
 
 169 
 
 444 
 
 143 
 
 354 
 
 339 
 
 201 
 
 420 
 
 153 
 
 271 
 
 1920 . 
 
 1030 
 
 165 
 
 502 
 
 163 
 
 528 
 
 167 
 
 363 
 
 334 
 
 185 
 
 347 
 
 178 
 
 321 
 
 BRONCHOPNEUMONIA. 
 
 1905 . 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1906 . 
 
 241 
 
 52 
 
 122 
 
 54 
 
 119 
 
 50 
 
 143 
 
 168 
 
 71 
 
 186 
 
 72 
 
 152 
 
 1907 . 
 
 227 
 
 49 
 
 123 
 
 54 
 
 104 
 
 43 
 
 128 
 
 149 
 
 64 
 
 165 
 
 64 
 
 135 
 
 1908 . 
 
 191 
 
 40 
 
 92 
 
 40 
 
 99 
 
 41 
 
 125 
 
 143 
 
 65 
 
 165 
 
 60 
 
 125 
 
 1909 . 
 
 225 
 
 47 
 
 122 
 
 52 
 
 103 
 
 42 
 
 155 
 
 175 
 
 73 
 
 182 
 
 82 
 
 169 
 
 1910 . 
 
 252 
 
 52 
 
 114 
 
 48 
 
 138 
 
 56 
 
 102 
 
 114 
 
 50 
 
 123 
 
 52 
 
 106 
 
 1911 . 
 
 273 
 
 56 
 
 137 
 
 57 
 
 136 
 
 55 
 
 139 
 
 153 
 
 77 
 
 187 
 
 62 
 
 125 
 
 1912 . 
 
 314 
 
 64 
 
 152 
 
 63 
 
 162 
 
 65 
 
 145 
 
 158 
 
 77 
 
 184 
 
 68 
 
 135 
 
 1913 . 
 
 375 
 
 75 
 
 191 
 
 78 
 
 184 
 
 73 
 
 189 
 
 203 
 
 92 
 
 217 
 
 97 
 
 191 
 
 1914 . 
 
 409 
 
 82 
 
 198 
 
 80 
 
 211 
 
 83 
 
 164 
 
 174 
 
 92 
 
 214 
 
 72 
 
 140 
 
 1915 . 
 
 363 
 
 72 
 
 172 
 
 69 
 
 191 
 
 75 
 
 178 
 
 186 
 
 89 
 
 204 
 
 89 
 
 171 
 
 1916 . 
 
 393 
 
 77 
 
 192 
 
 76 
 
 201 
 
 78 
 
 218 
 
 225 
 
 102 
 
 231 
 
 116 
 
 221 
 
 1917 . 
 
 383 
 
 74 
 
 215 
 
 84 
 
 168 
 
 65 
 
 206 
 
 211 
 
 112 
 
 250 
 
 94 
 
 177 
 
 1918 . 
 
 729 
 
 141 
 
 411 
 
 160 
 
 318 
 
 121 
 
 265 
 
 268 
 
 102 
 
 225 
 
 163 
 
 304 
 
 1919 . 
 
 474 
 
 77 
 
 257 
 
 84 
 
 217 
 
 70 
 
 186 
 
 178 
 
 109 
 
 228 
 
 77 
 
 137 
 
 1920 . 
 
 506 
 
 81 
 
 242 
 
 78 
 
 264 
 
 83 
 
 184 
 
 169 
 
 95 
 
 178 
 
 89 
 
 160 
 
 * The totals of these figures, which were obtained from special tables in the annual 
 reports, do not always correspond with those of the tables of deaths from all causes, but 
 their proportionate distribution by color and sex may be regarded as relatively accurate. 
 
FEBRILE DISEASES 
 
 367 
 
 Table 74 .—Number of deaths and rate of death, per 100,000 living inhabitants, from 
 
 pneumonia, bronchitis, etc. —Continued. 
 
 LOBAR PNEUMONIA. 
 
 Year. 
 
 White. 
 
 Colored. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 1905 . 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1906 . 
 
 409 
 
 88 
 
 207 
 
 92 
 
 202 
 
 85 
 
 229 
 
 270 
 
 135 
 
 353 
 
 94 
 
 199 
 
 1907 . 
 
 458 
 
 98 
 
 253 
 
 111 
 
 205 
 
 86 
 
 281 
 
 326 
 
 160 
 
 412 
 
 121 
 
 256 
 
 1908 . 
 
 392 
 
 83 
 
 201 
 
 87 
 
 191 
 
 79 
 
 232 
 
 266 
 
 120 
 
 304 
 
 112 
 
 234 
 
 1909 . 
 
 498 
 
 104 
 
 244 
 
 104 
 
 254 
 
 104 
 
 237 
 
 268 
 
 131 
 
 327 
 
 106 
 
 219 
 
 1910 . 
 
 518 
 
 107 
 
 281 
 
 119 
 
 237 
 
 96 
 
 187 
 
 209 
 
 110 
 
 271 
 
 77 
 
 157 
 
 1911 . 
 
 460 
 
 94 
 
 241 
 
 101 
 
 219 
 
 88 
 
 242 
 
 266 
 
 134 
 
 325 
 
 108 
 
 217 
 
 1912 . 
 
 373 
 
 76 
 
 197 
 
 81 
 
 176 
 
 70 
 
 216 
 
 235 
 
 122 
 
 292 
 
 94 
 
 187 
 
 1913 . 
 
 422 
 
 85 
 
 226 
 
 92 
 
 196 
 
 78 
 
 212 
 
 227 
 
 120 
 
 283 
 
 92 
 
 181 
 
 1914 . 
 
 425 
 
 85 
 
 244 
 
 99 
 
 181 
 
 71 
 
 203 
 
 215 
 
 112 
 
 261 
 
 91 
 
 177 
 
 1915 . 
 
 405 
 
 80 
 
 227 
 
 91 
 
 178 
 
 69 
 
 186 
 
 195 
 
 111 
 
 255 
 
 75 
 
 144 
 
 1916 . 
 
 554 
 
 109 
 
 311 
 
 123 
 
 243 
 
 94 
 
 237 
 
 245 
 
 140 
 
 317 
 
 97 
 
 185 
 
 1917 . 
 
 524 
 
 102 
 
 306 
 
 120 
 
 218 
 
 84 
 
 348 
 
 356 
 
 210 
 
 469 
 
 138 
 
 260 
 
 1918 . 
 
 1968 
 
 379 
 
 1127 
 
 439 
 
 841 
 
 321 
 
 565 
 
 571 
 
 326 
 
 719 
 
 239 
 
 445 
 
 1919 . 
 
 488 
 
 79 
 
 261 
 
 85 
 
 227 
 
 73 
 
 168 
 
 161 
 
 92 
 
 192 
 
 76 
 
 135 
 
 1920 .. 
 
 524 
 
 84 
 
 260 
 
 84 
 
 264 
 
 83 
 
 179 
 
 165 
 
 90 
 
 169 
 
 89 
 
 160 
 
 BRONCHITIS. 
 
 1905 . 
 
 1906 . 
 
 1907 . 
 
 1908 . 
 
 1909 . 
 
 1910 . 
 
 1911 . 
 
 1912 . 
 
 1913 . 
 
 1914 . 
 
 1915 . 
 
 1916 . 
 
 156 
 
 133 
 
 134 
 
 115 
 104 
 125 
 108 
 112 
 
 116 
 112 
 
 96 
 
 34 
 
 29 
 
 29 
 
 24 
 
 22 
 
 26 
 
 22 
 
 23 
 
 23 
 
 22 
 
 19 
 
 75 
 
 71 
 
 63 
 
 54 
 
 37 
 
 56 
 
 46 
 
 47 
 58 
 54 
 42 
 
 34 
 
 31 
 
 28 
 
 23 
 16 
 
 24 
 19 
 19 
 24 
 22 
 17 
 
 81 
 
 62 
 
 71 
 
 61 
 
 67 
 
 69 
 
 62 
 
 65 
 
 58 
 
 58 
 
 54 
 
 35 
 
 26 
 
 30 
 
 25 
 
 27 
 
 28 
 
 25 
 
 26 
 23 
 23 
 21 
 
 90 
 
 74 
 
 48 
 
 48 
 
 37 
 
 32 
 
 44 
 
 36 
 
 51 
 
 40 
 
 30 
 
 108 
 
 87 
 
 56 
 
 55 
 
 42 
 
 36 
 
 48 
 
 39 
 
 55 
 
 42 
 
 31 
 
 43 
 
 38 
 
 19 
 
 24 
 
 17 
 13 
 
 18 
 18 
 
 27 
 
 28 
 9 
 
 114 
 
 99 
 
 49 
 
 61 
 
 42 
 32 
 44 
 
 43 
 
 64 
 
 65 
 21 
 
 47 
 
 36 
 
 29 
 
 24 
 
 20 
 
 19 
 
 26 
 
 18 
 
 24 
 
 12 
 
 21 
 
 102 
 
 76 
 
 61 
 
 50 
 
 41 
 
 39 
 52 
 36 
 47 
 23 
 
 40 
 
 1917 . 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1918 . 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1919 . 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1920 . 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 of these rates are so clear that extended discussion is unnecessary. The wide 
 difference in the rates for pneumonia (broncho and lobar combined) in whites 
 and in negroes is striking. The general trend of the curves of these rates follow 
 each other closely; a marked difference occurs in only one year, 1910, when 
 there is a decided dip in the rate for colored, without a corresponding change 
 in the rate for white. The increase in the rate in the influenza year, 1918, is 
 notably greater in whites than in colored. 
 
 Similarly, the course of the curves for pneumonia in male and female white 
 and colored shows a remarkably close correspondence, a feature lacking in the 
 curves for bronchitis. The decidedly lower death-rates for pneumonia in females 
 in both races is evident. 
 
368 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 When the annual rates for each of these categories is averaged for pneumonia 
 for the period 1906-1920, and for bronchitis for the period 1905-1915, the rates 
 for white and colored stand in the following ratios to each other: Total pneu¬ 
 monia as 1: 2.47 (179 to 443) ; broncho-pneumonia as 1: 2.57 (69 to 178) ; 
 lobar pneumonia as 1:2.40 (110 to 265); and bronchitis as 1:2.19. Thus, 
 under each category the death-rate is greater by two and a quarter to two and 
 a half times in colored than in white. 
 
 The averaged rates for the same categories for sex and color show ratios as 
 follows: Total pneumonia, males to females, white 1.17 : 1 (194 to 166), colored 
 1.41:1 (526 to 374); broncho-pneumonia, males to females, white 1.08:1 
 (72 to 67), colored 1.20:1 (196 to 163); lobar pneumonia, males to females, 
 white 1.23 : 1 (122 to 99), colored, 1.57:1 (330 to 210); and bronchitis, males 
 to females, white 1: 1.13 (22 to 26), colored, 1.12: 1 (58 to 52). Therefore, 
 pneumonia, both broncho and lobar, is considerably more fatal for males than 
 for females of both races, and bronchitis is somewhat more fatal for white 
 females and for colored males. In like manner, when the totals for the absolute 
 figures for the deaths of whites and negroes during these periods are compared, 
 the ratios are heavily against the negro; total pneumonia, 1.96: 1, broncho¬ 
 pneumonia, 2.12:1, lobar pneumonia, 2.26:1, and bronchitis, 2.47:1, while 
 the proportion of negroes to whites in the population during this period was 
 as 1: 5.42. 
 
 Death-rates, specific in regard to age for sex and color for the census year 
 1910, for bronchitis, broncho-pneumonia, lobar pneumonia, and total pneu¬ 
 monia, are shown in table 75. Owing to certain small discrepancies in the 
 official tables and to the forced omission of pleural affections, the absolute 
 figures and the rates under the different categories are not in exact agreement 
 with those presented in previous tables. It is evident from inspection of the 
 
 Table 75 .—Number of deaths and rate of death, per 100,000 living inhabitants, from 
 bronchitis and pneumonia, according to age, for 1910. 
 
 D = death. R = rate. 
 TOTAL PNEUMONIA. 
 
 Age period. 
 
 Total. 
 
 White. 
 
 Colored. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 Under 1 year. 
 
 231 
 
 2256 
 
 154 
 
 1732 
 
 77 
 
 1715 
 
 77 
 
 1749 
 
 77 
 
 5712 
 
 44 
 
 6423 
 
 33 
 
 4962 
 
 Betw. 1 and 2 years 
 
 101 
 
 1051 
 
 78 
 
 919 
 
 42 
 
 958 
 
 36 
 
 878 
 
 23 
 
 2041 
 
 10 
 
 1795 
 
 13 
 
 2281 
 
 2 to 4 years. 
 
 94 
 
 293 
 
 59 
 
 211 
 
 29 
 
 206 
 
 30 
 
 216 
 
 35 
 
 842 
 
 23 
 
 1143 
 
 12 
 
 560 
 
 5 to 9 years. 
 
 22 
 
 44 
 
 17 
 
 39 
 
 8 
 
 37 
 
 9 
 
 42 
 
 5 
 
 78 
 
 1 
 
 33 
 
 4 
 
 119 
 
 Under 10 years.... 
 
 448 
 
 441 
 
 308 
 
 348 
 
 156 
 
 350 
 
 152 
 
 346 
 
 140 
 
 1073 
 
 78 
 
 1235 
 
 62 
 
 921 
 
 10 to 19 years. 
 
 27 
 
 26 
 
 17 
 
 19 
 
 11 
 
 26 
 
 6 
 
 13 
 
 10 
 
 73 
 
 5 
 
 85 
 
 5 
 
 63 
 
 20 to 29 years. 
 
 52 
 
 46 
 
 25 
 
 27 
 
 23 
 
 52 
 
 2 
 
 4 
 
 27 
 
 131 
 
 15 
 
 166 
 
 12 
 
 104 
 
 30 to 39 years. 
 
 83 
 
 93 
 
 53 
 
 72 
 
 24 
 
 67 
 
 29 
 
 77 
 
 30 
 
 190 
 
 20 
 
 261 
 
 10 
 
 123 
 
 40 to 49 years. 
 
 66 
 
 96 
 
 41 
 
 72 
 
 24 
 
 87 
 
 17 
 
 57 
 
 25 
 
 219 
 
 14 
 
 248 
 
 11 
 
 192 
 
 50 to 59 years. 
 
 99 
 
 219 
 
 79 
 
 202 
 
 45 
 
 238 
 
 34 
 
 169 
 
 20 
 
 330 
 
 12 
 
 405 
 
 8 
 
 258 
 
 60 to 69 years. 
 
 114 
 
 460 
 
 93 
 
 424 
 
 57 
 
 577 
 
 36 
 
 299 
 
 21 
 
 727 
 
 11 
 
 833 
 
 10 
 
 638 
 
 70 to 79 years. 
 
 113 
 
 1081 
 
 105 
 
 1110 
 
 38 
 
 965 
 
 67 
 
 1214 
 
 8 
 
 803 
 
 2 
 
 496 
 
 6 
 
 1012 
 
 80 years and over.. 
 
 57 
 
 2134 
 
 49 
 
 2063 
 
 17 
 
 1981 
 
 32 
 
 2109 
 
 8 
 
 2703 
 
 3 
 
 3226 
 
 5 
 
 2463 
 
 Total . 
 
 1059 
 
 190 
 
 770 
 
 163 
 
 395 
 
 173 
 
 ,375 
 
 153 
 
 289 
 
 340 
 
 160 
 
 406 
 
 129 
 
 282 
 
FEBRILE DISEASES 
 
 369 
 
 Table 75. —Number of deaths and rate of death, per 100,000 living inhabitants, from 
 bronchitis and pneumonia, according to age, for 1910. —Continued. 
 
 BRONCHOPNEUMONIA. 
 
 
 Ta+ n 1 
 
 White. 
 
 Colored. 
 
 
 1 Old** 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Age period. 
 
 
 
 Total. 
 
 Male. 
 
 Fern. 
 
 Total. 
 
 Male. 
 
 Fein. 
 
 
 D 
 
 R 
 
 D 
 
 R 
 
 n 
 
 it 
 
 D 
 
 It 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 Under 1 year. 
 
 140 
 
 1367 
 
 95 
 
 1069 
 
 45 
 
 1002 
 
 50 
 
 
 1136 
 
 45 
 
 3338 
 
 22 
 
 
 3212 
 
 23 
 
 3459 
 
 Betw. 1 and 2 years 
 
 54 
 
 562 
 
 43 
 
 507 
 
 27 
 
 616 
 
 16 
 
 
 390 
 
 11 
 
 976 
 
 5 
 
 
 898 
 
 6 
 
 1053 
 
 2 to 4 years. 
 
 46 
 
 143 
 
 27 
 
 97 
 
 12 
 
 85 
 
 15 
 
 
 108 
 
 19 
 
 457 
 
 11 
 
 
 547 
 
 8 
 
 373 
 
 5 to 9 years. 
 
 10 
 
 20 
 
 8 
 
 19 
 
 4 
 
 
 18 
 
 4 
 
 
 19 
 
 2 
 
 31 
 
 • • • 
 
 
 • • • • 
 
 2 
 
 60 
 
 Under 10 years.... 
 
 250 
 
 246 
 
 173 
 
 195 
 
 88 
 
 197 
 
 85 
 
 
 193 
 
 77 
 
 590 
 
 38 
 
 
 602 
 
 39 
 
 379 
 
 10 to 19 years. 
 
 3 
 
 3 
 
 1 
 
 1 
 
 1 
 
 
 2 
 
 • • • 
 
 
 • • • • 
 
 2 
 
 15 
 
 • . . 
 
 
 . . . . 
 
 2 
 
 25 
 
 20 to 29 years. 
 
 5 
 
 4 
 
 1 
 
 1 
 
 • • • 
 
 
 • • • • 
 
 1 
 
 
 2 
 
 4 
 
 19 
 
 2 
 
 
 22 
 
 2 
 
 17 
 
 30 to 39 years. 
 
 5 
 
 6 
 
 4 
 
 5 
 
 2 
 
 
 6 
 
 2 
 
 
 5 
 
 1 
 
 6 
 
 1 
 
 
 13 
 
 • • • 
 
 • • • • 
 
 40 to 49 years. 
 
 5 
 
 7 
 
 2 
 
 4 
 
 2 
 
 
 7 
 
 • • • 
 
 
 .... 
 
 3 
 
 26 
 
 3 
 
 
 53 
 
 • • • 
 
 • • • • 
 
 50 to 59 years. 
 
 14 
 
 31 
 
 9 
 
 23 
 
 4 
 
 
 21 
 
 5 
 
 
 25 
 
 5 
 
 82 
 
 3 
 
 
 101 
 
 2 
 
 64 
 
 60 to 69 years. 
 
 24 
 
 97 
 
 18 
 
 82 
 
 5 
 
 
 51 
 
 13 
 
 
 108 
 
 6 
 
 208 
 
 3 
 
 
 227 
 
 3 
 
 191 
 
 70 to 79 years. 
 
 31 
 
 297 
 
 28 
 
 296 
 
 8 
 
 203 
 
 20 
 
 
 362 
 
 3 
 
 301 
 
 • • • 
 
 
 • • • • 
 
 3 
 
 506 
 
 80 years and over.. 
 
 17 
 
 636 
 
 16 
 
 674 
 
 4 
 
 
 466 
 
 12 
 
 
 791 
 
 1 
 
 338 
 
 ... 
 
 
 • • • • 
 
 1 
 
 493 
 
 Total . 
 
 354 
 
 63 
 
 252 
 
 53 
 
 114 
 
 50 
 
 138 
 
 
 56 
 
 102 
 
 120 
 
 50 
 
 
 127 
 
 52 
 
 114 
 
 LOBAR PNEUMONIA. 
 
 Under 1 year. 
 
 91 
 
 889 
 
 59 
 
 664 
 
 32 
 
 713 
 
 27 
 
 613 
 
 32 
 
 2374 
 
 22 
 
 3212 
 
 10 
 
 1504 
 
 Betw. 1 and 2 years 
 
 47 
 
 489 
 
 35 
 
 412 
 
 15 
 
 342 
 
 20 
 
 488 
 
 12 
 
 1065 
 
 5 
 
 898 
 
 7 
 
 1228 
 
 2 to 4 years. 
 
 48 
 
 149 
 
 32 
 
 114 
 
 17 
 
 121 
 
 15 
 
 108 
 
 16 
 
 385 
 
 12 
 
 596 
 
 4 
 
 187 
 
 5 to 9 years. 
 
 12 
 
 24 
 
 9 
 
 21 
 
 4 
 
 18 
 
 5 
 
 23 
 
 3 
 
 47 
 
 1 
 
 33 
 
 2 
 
 60 
 
 Under 10 years.... 
 
 198 
 
 195 
 
 135 
 
 152 
 
 68 
 
 152 
 
 67 
 
 152 
 
 63 
 
 483 
 
 40 
 
 634 
 
 23 
 
 342 
 
 10 to 19 years. 
 
 24 
 
 23 
 
 16 
 
 18 
 
 10 
 
 23 
 
 6 
 
 13 
 
 8 
 
 58 
 
 5 
 
 85 
 
 3 
 
 38 
 
 20 to 29 years. 
 
 47 
 
 42 
 
 24 
 
 26 
 
 23 
 
 52 
 
 1 
 
 2 
 
 23 
 
 112 
 
 13 
 
 144 
 
 10 
 
 86 
 
 30 to 39 years. 
 
 78 
 
 87 
 
 49 
 
 67 
 
 22 
 
 62 
 
 27 
 
 71 
 
 29 
 
 183 
 
 19 
 
 248 
 
 10 
 
 123 
 
 40 to 49 years. 
 
 61 
 
 89 
 
 39 
 
 68 
 
 22 
 
 80 
 
 17 
 
 57 
 
 22 
 
 193 
 
 11 
 
 195 
 
 11 
 
 192 
 
 50 to 59 years. 
 
 85 
 
 188 
 
 70 
 
 179 
 
 41 
 
 217 
 
 29 
 
 144 
 
 15 
 
 247 
 
 9 
 
 304 
 
 6 
 
 193 
 
 60 to 69 years. 
 
 90 
 
 363 
 
 75 
 
 342 
 
 52 
 
 526 
 
 23 
 
 191 
 
 15 
 
 519 
 
 8 
 
 606 
 
 7 
 
 446 
 
 70 to 79 years. 
 
 82 
 
 784 
 
 77 
 
 814 
 
 30 
 
 762 
 
 47 
 
 852 
 
 5 
 
 502 
 
 2 
 
 496 
 
 3 
 
 506 
 
 80 years and over.. 
 
 40 
 
 1498 
 
 33 
 
 1389 
 
 13 
 
 1515 
 
 20 
 
 1318 
 
 7 
 
 2365 
 
 3 
 
 3226 
 
 4 
 
 1970 
 
 Total . 
 
 705 
 
 126 
 
 518 
 
 109 
 
 281 
 
 123 
 
 237 
 
 97 
 
 187 
 
 220 
 
 110 
 
 279 
 
 77 
 
 168 
 
 BRONCHITIS. 
 
 Under 1 year. 
 
 32 
 
 313 
 
 24 
 
 270 
 
 8 
 
 178 
 
 16 
 
 363 
 
 8 
 
 593 
 
 4 
 
 584 
 
 4 
 
 602 
 
 Betw. 1 and 2 years 
 
 11 
 
 114 
 
 6 
 
 71 
 
 3 
 
 68 
 
 3 
 
 73 
 
 5 
 
 444 
 
 3 
 
 539 
 
 2 
 
 351 
 
 2 to 4 years. 
 
 10 
 
 31 
 
 8 
 
 29 
 
 2 
 
 14 
 
 6 
 
 43 
 
 2 
 
 48 
 
 1 
 
 50 
 
 1 
 
 47 
 
 5 to 9 years. 
 
 3 
 
 6 
 
 3 
 
 7 
 
 1 
 
 5 
 
 2 
 
 9 
 
 
 
 
 
 
 
 Under 10 years.... 
 
 56 
 
 55 
 
 41 
 
 46 
 
 14 
 
 31 
 
 27 
 
 61 
 
 15 
 
 115 
 
 8 
 
 127 
 
 7 
 
 104 
 
 10 to 19 years. 
 
 5 
 
 5 
 
 
 
 
 
 
 
 5 
 
 36 
 
 • • • 
 
 • • • • 
 
 5 
 
 63 
 
 20 to 29 years. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 30 to 39 years. 
 
 6 
 
 7 
 
 3 
 
 4 
 
 3 
 
 8 
 
 • • • 
 
 • • • • 
 
 3 
 
 19 
 
 2 
 
 26 
 
 1 
 
 12 
 
 40 to 49 years. 
 
 5 
 
 7 
 
 1 
 
 2 
 
 1 
 
 4 
 
 • • • 
 
 • • • • 
 
 4 
 
 35 
 
 2 
 
 35 
 
 2 
 
 35 
 
 50 to 59 years. 
 
 3 
 
 7 
 
 3 
 
 8 
 
 2 
 
 11 
 
 1 
 
 5 
 
 
 
 
 
 
 
 60 to 69 years. 
 
 21 
 
 85 
 
 19 
 
 87 
 
 13 
 
 132 
 
 6 
 
 50 
 
 2 
 
 69 
 
 ... 
 
 • • • • 
 
 2 
 
 128 
 
 70 to 79 years. 
 
 30 
 
 287 
 
 29 
 
 307 
 
 16 
 
 406 
 
 13 
 
 236 
 
 1 
 
 100 
 
 • • • 
 
 • • • • 
 
 1 
 
 169 
 
 80 years and over.. 
 
 31 
 
 1161 
 
 29 
 
 1221 
 
 7 
 
 816 
 
 22 
 
 1450 
 
 2 
 
 676 
 
 1 
 
 1075 
 
 1 
 
 493 
 
 Total . 
 
 157 
 
 28 
 
 125 
 
 26 
 
 56 
 
 24 
 
 69 
 
 28 
 
 32 
 
 38 
 
 13 
 
 33 
 
 19 
 
 42 
 
 table that the general course of the curves for bronchitis and both broncho- 
 and lobar pneumonia is similar, and that age has exerted an enormously 
 important influence upon the rates in both whites and negroes. For bron¬ 
 chitis, the lower rates occur in whites between 10 and 50 years and in negroes 
 between 20 and 40 years. For broncho-pneumonia, the lowest death-rates 
 
370 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 fall in whites between 20 and 60 years and in blacks between 20 and 50 
 years. In this affection, as officially classified, the rates show a drop in the 
 third decade in whites and in the fourth decade in negroes, and for bronchitis 
 no deaths are credited to negroes in the third and fourth decades of life. In 
 both of these affections the death-rates are higher under the tenth year in 
 negroes than in whites, while after the seventy-ninth year the reverse is the 
 case. If the rates for bronchitis and broncho-pneumonia were combined, on 
 the whole, the curve of the plotted figures would not depart materially from 
 that for broncho-pneumonia alone. 
 
 In lobar pneumonia, as in the other two affections examined, the highest 
 rates are met with at the extremes of age. The rates for negroes are con¬ 
 siderably higher than those for whites throughout the life-span. The lowest 
 rates for whites lie between the tenth and the fiftieth year and those for negroes 
 between the tenth and the thirtieth year. The rates for negroes are at all ages 
 uniformly higher than those for whites. In both races there is a little change 
 in the rates between the fourth and fifth decades. While the rates for lobar 
 pneumonia are lower in the earlier years of life, they are higher throughout 
 than those for broncho-pneumonia. 
 
 The courses of the combined rates for broncho- and lobar pneumonia show 
 perhaps more accurately the relation of age and race to pneumonia mortality. 
 In bronchitis, the female total rate is significantly higher than the male in 
 whites; the rate for males is greater than that for females in every decade 
 except the first year and for 80 years and over. In the colored, the female rate 
 is 20 per cent higher than the male rate for all ages and for each decade except 
 the first, fourth, fifth, and 80 years and over. There were no deaths in colored 
 males in the second, third, sixth, seventh, and eighth decades. For broncho¬ 
 pneumonia in whites, the total female rate is 10 per cent greater than the 
 male, but there is very little difference in the rates for the two sexes before 
 the seventh decade, after which the rate in females is markedly higher. In 
 the colored, the total rate is greater in males by 10 per cent and the rates are 
 higher in this sex uniformly until the seventh decade, after which the rates for 
 females are not markedly in excess. In lobar pneumonia the total rate for 
 males is 21 per cent greater than that for females, and the male rate exceeds 
 the female rate in every decade except the fourth and over 70 years. In the 
 negro, the male rate is much higher in the first four decades. In the sixth and 
 seventh decades and 80 years and over, the female rates are higher. In the 
 eighth decade, the rates for the two sexes are equal. For the whole life-span, 
 the male rates are 36 per cent greater than the female. In broncho- and lobar 
 pneumonia taken together for whites, the rate for all ages is 11.5 per cent 
 greater in males, in whom higher rates are met in each decade except the 
 fourth and after 70 years, when the rates for females are considerably higher. 
 In the colored race, the rate for all ages is 30 per cent higher in males, and 
 the rates for the separate decades, except after the seventh, are considerably 
 higher in the male. 
 
 The rates for the same categories in 1920 (table 76), which differing in many 
 respects from those for 1910, shows, in the main, very much the same propor¬ 
 tional distribution of mortality by age, color and sex. 
 
 When on the basis of rates specific for age for the total population, for whites 
 and for negroes, the mortality from all forms of pneumonia and from all 
 
FEBRILE DISEASES 
 
 371 
 
 Table 76 .—Number of deaths, and rate of death, per 100,000 living inhabitants, from 
 pneumonia and bronchitis, according to age, color, and sex, for 1920. 
 
 D = death. It = rate. 
 
 TOTAL PNEUMONIA. 
 
 Age-groups. 
 
 Total. 
 
 White. 
 
 Colored. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 Under I year. 
 
 275 
 
 1852 
 
 181 
 
 1405 
 
 95 
 
 1439 
 
 86 
 
 1369 
 
 94 
 
 4776 
 
 53 
 
 5538 
 
 41 
 
 4055 
 
 1 to 4 years. 
 
 174 
 
 319 
 
 113 
 
 235 
 
 55 
 
 228 
 
 58 
 
 242 
 
 6.1 
 
 952 
 
 31 
 
 996 
 
 30 
 
 911 
 
 0 to 4 years. 
 
 449 
 
 647 
 
 294 
 
 482 
 
 150 
 
 488 
 
 144 
 
 332 
 
 155 
 
 1851 
 
 84 
 
 2064 
 
 71 
 
 1649 
 
 5 to 9 years. 
 
 32 
 
 50 
 
 24 
 
 43 
 
 14 
 
 49 
 
 10 
 
 36 
 
 8 
 
 99 
 
 6 
 
 155 
 
 2 
 
 48 
 
 0 to 9 years. 
 
 481 
 
 359 
 
 318 
 
 271 
 
 164 
 
 276 
 
 154 
 
 265 
 
 163 
 
 991 
 
 90 
 
 1135 
 
 73 
 
 858 
 
 10 to 19 years. 
 
 41 
 
 33 
 
 29 
 
 27 
 
 15 
 
 28 
 
 14 
 
 25 
 
 12 
 
 75 
 
 5 
 
 71 
 
 7 
 
 79 
 
 20 to 29 years. 
 
 152 
 
 105 
 
 106 
 
 89 
 
 46 
 
 78 
 
 60 
 
 100 
 
 46 
 
 178 
 
 24 
 
 197 
 
 22 
 
 161 
 
 30 to 39 years. 
 
 162 
 
 132 
 
 123 
 
 122 
 
 67 
 
 133 
 
 56 
 
 112 
 
 39 
 
 179 
 
 19 
 
 172 
 
 20 
 
 186 
 
 40 to 49 years. 
 
 129 
 
 140 
 
 85 
 
 111 
 
 39 
 
 102 
 
 46 
 
 119 
 
 44 
 
 283 
 
 20 
 
 241 
 
 24 
 
 329 
 
 50 to 59 years. 
 
 139 
 
 222 
 
 112 
 
 205 
 
 58 
 
 217 
 
 54 
 
 193 
 
 27 
 
 344 
 
 15 
 
 353 
 
 12 
 
 332 
 
 60 to 69 years. 
 
 134 
 
 372 
 
 116 
 
 356 
 
 60 
 
 392 
 
 56 
 
 325 
 
 18 
 
 519 
 
 5 
 
 292 
 
 13 
 
 742 
 
 70 to 79 years. 
 
 108 
 
 749 
 
 101 
 
 773 
 
 41 
 
 733 
 
 60 
 
 804 
 
 7 
 
 516 
 
 4 
 
 661 
 
 3 
 
 399 
 
 80 years and over. 
 
 47 
 
 135 
 
 40 
 
 128 
 
 12 
 
 599 
 
 28 
 
 1398 
 
 7 
 
 1977 
 
 3 
 
 2239 
 
 4 
 
 1818 
 
 Total . 
 
 1393 
 
 190 
 
 1030 
 
 165 
 
 502 
 
 163 
 
 528 
 
 167 
 
 363 
 
 334 
 
 185 
 
 348 
 
 178 
 
 321 
 
 BRONCHOPNEUMONIA. 
 
 Under 1 year. 
 
 230 
 
 1549 
 
 148 
 
 1149 
 
 76 
 
 1152 
 
 72 
 
 1146 
 
 82 
 
 4167 
 
 47 
 
 4911 
 
 35 
 
 3462 
 
 1 to 4 years. 
 
 127 
 
 233 
 
 81 
 
 168 
 
 39 
 
 162 
 
 42 
 
 175 
 
 46 
 
 718 
 
 24 
 
 771 
 
 22 
 
 668 
 
 0 to 4 years. 
 
 357 
 
 515 
 
 229 
 
 376 
 
 115 
 
 374 
 
 114 
 
 263 
 
 128 
 
 1528 
 
 71 
 
 1744 
 
 57 
 
 1324 
 
 5 to 9 years. 
 
 18 
 
 28 
 
 14 
 
 25 
 
 8 
 
 28 
 
 6 
 
 22 
 
 4 
 
 50 
 
 3 
 
 78 
 
 1 
 
 24 
 
 0 to 9 years. 
 
 375 
 
 280 
 
 243 
 
 207 
 
 123 
 
 207 
 
 120 
 
 207 
 
 132 
 
 803 
 
 74 
 
 933 
 
 58 
 
 681 
 
 10 to 19 years. 
 
 15 
 
 12 
 
 13 
 
 12 
 
 5 
 
 9 
 
 8 
 
 15 
 
 2 
 
 13 
 
 2 
 
 28 
 
 • • • 
 
 • • • • 
 
 20 to 29 years. 
 
 42 
 
 29 
 
 35 
 
 29 
 
 18 
 
 31 
 
 17 
 
 28 
 
 7 
 
 27 
 
 1 
 
 8 
 
 6 
 
 44 
 
 30 to 39 years. 
 
 32 
 
 26 
 
 25 
 
 25 
 
 12 
 
 24 
 
 13 
 
 26 
 
 7 
 
 32 
 
 4 
 
 36 
 
 3 
 
 28 
 
 40 to 49 years. 
 
 32 
 
 35 
 
 20 
 
 26 
 
 10 
 
 26 
 
 10 
 
 26 
 
 12 
 
 77 
 
 4 
 
 48 
 
 8 
 
 110 
 
 50 to 59 years. 
 
 40 
 
 64 
 
 33 
 
 60 
 
 15 
 
 56 
 
 18 
 
 64 
 
 7 
 
 89 
 
 4 
 
 94 
 
 3 
 
 83 
 
 60 to 69 years. 
 
 58 
 
 161 
 
 50 
 
 154 
 
 28 
 
 183 
 
 22 
 
 128 
 
 8 
 
 231 
 
 2 
 
 117 
 
 6 
 
 342 
 
 70 to 79 years. 
 
 64 
 
 444 
 
 60 
 
 459 
 
 23 
 
 411 
 
 37 
 
 496 
 
 4 
 
 295 
 
 2 
 
 331 
 
 2 
 
 266 
 
 80 years and over. 
 
 32 
 
 92 
 
 27 
 
 86 
 
 8 
 
 399 
 
 19 
 
 949 
 
 5 
 
 1412 
 
 2 
 
 1493 
 
 3 
 
 1364 
 
 Total . 
 
 690 
 
 94 
 
 506 
 
 81 
 
 242 
 
 78 
 
 264 
 
 83 
 
 184 
 
 169 
 
 95 
 
 178 
 
 89 
 
 160 
 
 LOBAR PNEUMONIA 
 
 Under 1 year. 
 
 45 
 
 303 
 
 1 to 4 years. 
 
 47 
 
 86 
 
 0 to 4 years. 
 
 92 
 
 133 
 
 5 to 9 years. 
 
 14 
 
 22 
 
 0 to 9 years. 
 
 106 
 
 79 
 
 10 to 19 years. 
 
 26 
 
 21 
 
 20 to 29 years. 
 
 110 
 
 76 
 
 30 to 39 years. 
 
 130 
 
 106 
 
 40 to 49 years. 
 
 97 
 
 105 
 
 50 to 59 years. 
 
 99 
 
 158 
 
 60 to 69 years. 
 
 76 
 
 211 
 
 70 to 79 years. 
 
 44 
 
 305 
 
 80 years and over. 
 
 15 
 
 43 
 
 Total . 
 
 703 
 
 96 
 
 33 
 
 256 
 
 19 
 
 288 
 
 14 
 
 223 
 
 32 
 
 67 
 
 16 
 
 66 
 
 16 
 
 67 
 
 65 
 
 107 
 
 35 
 
 114 
 
 30 
 
 69 
 
 10 
 
 18 
 
 6 
 
 21 
 
 4 
 
 14 
 
 75 
 
 64 
 
 41 
 
 69 
 
 34 
 
 59 
 
 16 
 
 15 
 
 10 
 
 19 
 
 6 
 
 11 
 
 71 
 
 60 
 
 28 
 
 48 
 
 43 
 
 71 
 
 98 
 
 97 
 
 55 
 
 109 
 
 43 
 
 86 
 
 65 
 
 85 
 
 29 
 
 76 
 
 36 
 
 93 
 
 79 
 
 144 
 
 43 
 
 161 
 
 36 
 
 128 
 
 66 
 
 203 
 
 32 
 
 209 
 
 34 
 
 197 
 
 41 
 
 314 
 
 18 
 
 322 
 
 23 
 
 308 
 
 13 
 
 42 
 
 4 
 
 200 
 
 9 
 
 449 
 
 524 
 
 84 
 
 260 
 
 84 
 
 264 
 
 83 
 
 12 
 
 610 
 
 6 
 
 627 
 
 6 
 
 593 
 
 15 
 
 234 
 
 7 
 
 225 
 
 8 
 
 243 
 
 27 
 
 322 
 
 13 
 
 319 
 
 14 
 
 325 
 
 4 
 
 50 
 
 3 
 
 78 
 
 1 
 
 24 
 
 31 
 
 189 
 
 16 
 
 202 
 
 15 
 
 176 
 
 10 
 
 63 
 
 3 
 
 42 
 
 7 
 
 79 
 
 39 
 
 151 
 
 23 
 
 189 
 
 16 
 
 117 
 
 32 
 
 147 
 
 15 
 
 136 
 
 17 
 
 158 
 
 32 
 
 205 
 
 16 
 
 193 
 
 16 
 
 219 
 
 20 
 
 255 
 
 11 
 
 259 
 
 9 
 
 249 
 
 10 
 
 289 
 
 3 
 
 175 
 
 7 
 
 400 
 
 3 
 
 221 
 
 2 
 
 331 
 
 1 
 
 133 
 
 2 
 
 565 
 
 1 
 
 746 
 
 1 
 
 455 
 
 179 
 
 165 
 
 90 
 
 169 
 
 89 
 
 160 
 
372 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 Table 76 .—Number of deaths and rate of death, per 100,000 living inhabitants, from 
 
 pneumonia and bronchitis, etc. —Continued. 
 
 BRONCHITIS. 
 
 White. 
 
 Colored. 
 
 Age-groups. 
 
 loiai* 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 Under 1 year. 
 
 34 
 
 229 
 
 22 
 
 171 
 
 11 
 
 167 
 
 11 
 
 175 
 
 12 
 
 610 
 
 7 
 
 731 
 
 5 
 
 495 
 
 1 to 4 years. 
 
 13 
 
 24 
 
 6 
 
 12 
 
 3 
 
 12 
 
 3 
 
 13 
 
 7 
 
 109 
 
 3 
 
 96 
 
 4 
 
 121 
 
 0 to 4 years. 
 
 47 
 
 68 
 
 28 
 
 46 
 
 14 
 
 46 
 
 14 
 
 32 
 
 19 
 
 227 
 
 10 
 
 246 
 
 9 
 
 209 
 
 5 to 9 years. 
 
 2 
 
 3 
 
 I 
 
 2 
 
 1 
 
 3 
 
 • • • 
 
 • • • • 
 
 1 
 
 12 
 
 1 
 
 26 
 
 • • • 
 
 • • • • 
 
 0 to 9 years. 
 
 49 
 
 37 
 
 29 
 
 25 
 
 15 
 
 25 
 
 14 
 
 24 
 
 20 
 
 122 
 
 11 
 
 139 
 
 9 
 
 106 
 
 10 to IQ vpara 
 
 1 
 
 1 
 
 
 
 
 
 
 
 1 
 
 6 
 
 1 
 
 14 
 
 
 
 20 to 29 years. 
 
 1 
 
 1 
 
 1 
 
 1 
 
 1 
 
 2 
 
 
 
 
 
 
 
 
 
 30 to 39 years. 
 
 5 
 
 4 
 
 4 
 
 4 
 
 1 
 
 2 
 
 3 
 
 6 
 
 1 
 
 5 
 
 • • • 
 
 • • • • 
 
 1 
 
 9 
 
 40 to 49 vears. 
 
 1 
 
 1 
 
 1 
 
 1 
 
 
 
 1 
 
 3 
 
 
 
 
 
 
 
 50 to 59 years. 
 
 2 
 
 3 
 
 2 
 
 4 
 
 2 
 
 7 
 
 
 
 
 
 
 
 
 
 60 to 69 years. 
 
 5 
 
 14 
 
 4 
 
 12 
 
 • • • 
 
 • • • • 
 
 4 
 
 23 
 
 1 
 
 29 
 
 • • • 
 
 • • • • 
 
 1 
 
 57 
 
 70 t.o 79 years. 
 
 7 
 
 49 
 
 7 
 
 54 
 
 3 
 
 54 
 
 4 
 
 54 
 
 
 
 
 
 
 
 80 years and over. 
 
 13 
 
 37 
 
 12 
 
 38 
 
 4 
 
 200 
 
 8 
 
 399 
 
 1 
 
 282 
 
 1 
 
 746 
 
 • • • 
 
 • • • • 
 
 Total . 
 
 84 
 
 11 
 
 60 
 
 10 
 
 26 
 
 8 
 
 34 
 
 11 
 
 24 
 
 22 
 
 13 
 
 24 
 
 11 
 
 20 
 
 causes of death in 1920 are compared (tables 76 and 136, graph 20) the shapes 
 of the respective curves from the first to the eighth decade of life are strikingly 
 similar. In all there is the same marked drop in the second decade from the high 
 level of the first, with a decided rise in the third decade. For the total popula¬ 
 tion the rates ascend in much the same degree from the third to the seventh 
 decade of life. The mortality from pneumonia fails to rise, in negroes, between 
 the third to the fourth, and, in whites, between the fourth and fifth decades, 
 and after the seventy-ninth year the pneumonia-rate falls in whites and rises 
 in negroes. With these minor exceptions, however, the parallelism is very 
 close. Remarkably similar agreements exist also in the course of rates specific 
 for sex and age. While the rates for all causes include, of course, those for 
 pneumonia, the latter bear too small a proportion to the whole to seriously 
 vitiate the comparison. It would appear, then, that the risk of dying in the 
 various decades of life from pneumonia varied directly with the risk of dying 
 from some one of all the remaining causes of death, i. e., of dying at all. 
 
 But the category all forms of pneumonia consists of at least two very dis¬ 
 tinctly different elements. Lobar pneumonia differs from broncho-pneumonia 
 (including bronchitis) in two essential features, namely, that it is both etio- 
 logically and pathologico-anatomically a specific disease. Broncho-pneumonia 
 represents, on the other hand, a heterogeneous congeries of acute lung infections 
 caused by a variety of pyogenic organisms. Therefore, these two forms of 
 pneumonia must be considered separately. For this purpose their courses in 
 rates specific for age for the whole population are compared with that for all 
 causes of death on graph 20. 
 
 It is evident that during the first 10 years of life, though on widely different 
 levels (the mortality from broncho-pneumonia being much higher than that 
 from lobar pneumonia), the rates for both these affections exhibit the charac¬ 
 teristics of such acute specific infections as scarlet fever, measles, whooping- 
 cough, and diphtheria. They are both characterized by high rates during the 
 first and by low rates during the second decade of life. Unlike the specific 
 infections above mentioned, both forms of pneumonia show rising rates after 
 
FEBRILE DISEASES 
 
 373 
 
 the second decade of life. As between themselves, however, there are marked 
 differences in degree of lethal force. The mortality for broncho-pneumonia 
 is much greater in the first and much less in the second decade than that 
 for lobar pneumonia. The mortality for the latter rises to a higher level in the 
 third decade (when it is nearly as high as in the first) and, except for a stand¬ 
 still between 40 and 49 years, continues to mount by gradual steps up to the 
 eightieth year. With broncho-pneumonia, on the other hand, the rate of mor¬ 
 tality, after remaining stationary on a very low level between the thirtieth 
 and forty-ninth years of life, rises comparatively abruptly and in the eighth 
 decade far surpasses that for lobar pneumonia. After the seventy-ninth year of 
 life the mortality for both forms of pneumonia falls notably, but the rate for 
 broncho-pneumonia is more than double that for lobar pneumonia. 
 
 Graph 20 (from tables 76 and 136). Comparison of mortality-rates specific 
 for age from total pneumonia and from lobar and broncho-pneumonia, and 
 from all causes of death, in 1920. 
 
 As compared with the course of the rates for deaths from all causes, broncho¬ 
 pneumonia conforms more closely during the first 10 years and lobar pneu¬ 
 monia during the remainder of life. In respect to the influence of age 
 upon rate of mortality, therefore, both these two forms of pneumonia depart 
 in a striking manner from the other acute febrile diseases for which local 
 data for comparison exist, and as between each other they present certain 
 marked differences. 
 
 Broncho-pneumonia furnishes an example of the influence of age, or 
 rather of the qualities that vary with age, upon the resistance of the lungs 
 to fatal infection with the pyogenic bacteria as a group. This resistance is 
 peculiarly weak in the extremes of life and particularly strong between 5 
 and 50 years of age. With lobar pneumonia the resistance to death is only 
 relatively weak in the first 5 years of life, high from the fifth to the nine- 
 
374 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 teenth year and thereafter steadily and notably decreasing until the eightieth 
 year. In this latter period its course of mortality closely parallels that for all 
 causes of death. In these respects lobar pneumonia is unique among the 
 specific febrile diseases analyzed in this material. 
 
 As exposure to pneumonia is in general terms not selective, these phe¬ 
 nomena suggest among other things that the forces of natural immunity 
 which participate in the control of mortality from lobar and broncho-pneu¬ 
 monia in the various age-periods differ, in part at least, in their seats or in 
 their modes of action. The fact that the age distribution of mortality from 
 lobar pneumonia follows so closely the path of all causes of death, and there¬ 
 fore seems to be more intimately associated with general constitutional vigor, 
 suggests that for this type of pneumonia natural resistance is mainly gen¬ 
 eral or constitutional rather than local. The in some respects contrary 
 behavior of mortality for the non-specific broncho-pneumonia provokes the 
 suggestion that the chief seat of resistance is local, i. e., in the lungs. These 
 aberrations do not, however, warrant the view that general constitutional 
 resistance plays no part in the one disease and local resistance is unim¬ 
 portant in the other, but they do indicate that as between the two affections 
 there are differences in this regard. It is a significant fact that for lobar 
 pneumonia the relative immunity from death acquired by the individual 
 after passing through infancy and childhood to puberty, a quality which 
 it shares with so many acute specific infections, is, contrary to what ob¬ 
 tains with them, no higher in the third than in the first decade, and after 
 this period steadily diminishes during the remainder of life. Of signifi¬ 
 cance also is the behavior of resistance of the individual to death from 
 lung infection with the mixture of pyogenic bacteria concerned with the 
 causation of broncho-pneumonia, as exemplified by the low death-rate be¬ 
 tween the tenth and the forty-ninth years, with the marked rise into the 
 period of old age. 
 
 Pneumonia, both lobar and broncho, was made reportable in 1917, but 
 the reporting of cases has not been complete enough for definite conclusions 
 in regard to case fatality. The cases reported in 1921 were tabulated ac¬ 
 cording to color, sex, and age. While, perhaps, they were not all cases of 
 primary pneumonia, and in number they certainly fall short of actual oc¬ 
 currence (there were only 2,095 cases as compared with 1,001 deaths, and 
 the death certificates were not cross-checked with the cards of reported cases 
 in order to add to the list of the latter individuals recorded as dying of 
 pneumonia but not reported as cases previous to death), their proportional 
 distribution according to these three categories is probably accurate enough 
 to justify comparison of the specific rates presented in table 77. 
 
 It will be observed that in their general trend the morbidity-rates for 
 the various categories agree with the corresponding mortality rates for 1920. 
 For all forms of pneumonia and for both lobar and broncho-pneumonia the 
 morbidity-rates of the population at all ages are higher in negroes than 
 in whites and in females than in males of both races. In the first twenty 
 years of life the age distribution of cases also agrees closely in trend with 
 that for deaths in 1920. In the third decade of life morbidity decreases 
 in the white and increases in the negro. There is a gradual rise in the 
 rates in whites during the third and fourth and in negroes from the third 
 
FEBRILE DISEASES 
 
 375 
 
 Table 77. —Number of cases and rate of morbidity, per 100J000 living inhabitants, in 
 1920, from pneumonia, according to age, color, and sex, in 1921 
 
 C = cases. R = rate. 
 
 TOTAL PNEUMONIA. 
 
 White. 
 
 Colored. 
 
 Age-groups. 
 
 luiai. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 c 
 
 R 
 
 C 
 
 R 
 
 C 
 
 R 
 
 C 
 
 R 
 
 C 
 
 R 
 
 C 
 
 R 
 
 C 
 
 R 
 
 Under 1 year. 
 
 253 
 
 1703 
 
 201 
 
 1560 
 
 110 
 
 1667 
 
 91 
 
 1448 
 
 52 
 
 2642 
 
 23 
 
 2403 
 
 29 
 
 2868 
 
 1 to 4 years. 
 
 445 
 
 816 
 
 378 
 
 786 
 
 204 
 
 845 
 
 174 
 
 726 
 
 67 
 
 1046 
 
 33 
 
 1060 
 
 34 
 
 1032 
 
 0 to 4 years. 
 
 698 
 
 1006 
 
 579 
 
 949 
 
 314 
 
 1021 
 
 265 
 
 611 
 
 119 
 
 1421 
 
 56 
 
 1376 
 
 63 
 
 1463 
 
 5 to 9 years. 
 
 232 
 
 360 
 
 211 
 
 374 
 
 128 
 
 448 
 
 83 
 
 298 
 
 21 
 
 260 
 
 13 
 
 337 
 
 8 
 
 190 
 
 0 to 9 vears. 
 
 930 
 
 695 
 
 790 
 
 673 
 
 442 
 
 745 
 
 348 
 
 599 
 
 140 
 
 851 
 
 69 
 
 870 
 
 71 
 
 834 
 
 10 to 19 years. 
 
 192 
 
 155 
 
 159 
 
 148 
 
 105 
 
 199 
 
 54 
 
 98 
 
 33 
 
 207 
 
 16 
 
 226 
 
 17 
 
 191 
 
 20 to 29 years. 
 
 194 
 
 134 
 
 136 
 
 114 
 
 78 
 
 133 
 
 58 
 
 96 
 
 58 
 
 225 
 
 35 
 
 287 
 
 23 
 
 169 
 
 30 to 39 years. 
 
 185 
 
 151 
 
 128 
 
 127 
 
 62 
 
 123 
 
 66 
 
 132 
 
 57 
 
 261 
 
 39 
 
 353 
 
 18 
 
 167 
 
 40 to 49 years. 
 
 150 
 
 162 
 
 105 
 
 137 
 
 64 
 
 168 
 
 41 
 
 106 
 
 45 
 
 289 
 
 26 
 
 314 
 
 19 
 
 261 
 
 50 to 59 years. 
 
 154 
 
 246 
 
 128 
 
 234 
 
 71 
 
 266 
 
 57 
 
 203 
 
 26 
 
 331 
 
 12 
 
 283 
 
 14 
 
 387 
 
 60 to 69 years. 
 
 146 
 
 405 
 
 123 
 
 378 
 
 57 
 
 372 
 
 66 
 
 383 
 
 23 
 
 664 
 
 11 
 
 642 
 
 12 
 
 685 
 
 70 to 79 years. 
 
 111 
 
 770 
 
 102 
 
 781 
 
 35 
 
 625 
 
 67 
 
 898 
 
 9 
 
 664 
 
 5 
 
 826 
 
 4 
 
 533 
 
 80 years and over. 
 
 33 
 
 95 
 
 31 
 
 99 
 
 12 
 
 599 
 
 19 
 
 949 
 
 2 
 
 565 
 
 • • • 
 
 .... 
 
 2 
 
 909 
 
 Total . 
 
 2095 
 
 285 
 
 1702 
 
 272 
 
 926 
 
 300 
 
 776 
 
 245 
 
 393 
 
 362 
 
 213 
 
 400 
 
 180 
 
 325 
 
 BRONCHO-PNEUMONIA. 
 
 Under 1 year. 
 
 214 
 
 1441 
 
 170 
 
 1319 
 
 92 
 
 1394 
 
 78 
 
 1241 
 
 44 
 
 2236 
 
 21 
 
 2194 
 
 23 
 
 2275 
 
 1 to 4 years. 
 
 311 
 
 571 
 
 260 
 
 540 
 
 134 
 
 555 
 
 126 
 
 526 
 
 51 
 
 796 
 
 25 
 
 803 
 
 26 
 
 789 
 
 0 to 4 years. 
 
 525 
 
 757 
 
 430 
 
 705 
 
 226 
 
 735 
 
 204 
 
 471 
 
 95 
 
 1134 
 
 46 
 
 1130 
 
 49 
 
 1138 
 
 5 to 9 years. 
 
 123 
 
 191 
 
 109 
 
 193 
 
 67 
 
 234 
 
 42 
 
 151 
 
 14 
 
 174 
 
 9 
 
 233 
 
 5 
 
 119 
 
 0 to 9 years. 
 
 648 
 
 484 
 
 539 
 
 459 
 
 293 
 
 494 
 
 246 
 
 424 
 
 109 
 
 663 
 
 55 
 
 693 
 
 54 
 
 634 
 
 10 to 19 years. 
 
 66 
 
 53 
 
 51 
 
 47 
 
 38 
 
 72 
 
 13 
 
 24 
 
 15 
 
 94 
 
 8 
 
 113 
 
 7 
 
 79 
 
 20 to 29 years. 
 
 58 
 
 40 
 
 43 
 
 36 
 
 17 
 
 29 
 
 26 
 
 43 
 
 15 
 
 58 
 
 9 
 
 74 
 
 6 
 
 44 
 
 30 to 39 years. 
 
 64 
 
 52 
 
 45 
 
 45 
 
 15 
 
 30 
 
 30 
 
 60 
 
 19 
 
 87 
 
 13 
 
 118 
 
 6 
 
 56 
 
 40 to 49 years. 
 
 60 
 
 65 
 
 40 
 
 52 
 
 20 
 
 52 
 
 20 
 
 52 
 
 20 
 
 128 
 
 12 
 
 145 
 
 8 
 
 110 
 
 50 to 59 years. 
 
 73 
 
 117 
 
 56 
 
 102 
 
 31 
 
 116 
 
 25 
 
 89 
 
 17 
 
 216 
 
 8 
 
 188 
 
 9 
 
 249 
 
 60 to 69 years. 
 
 62 
 
 172 
 
 49 
 
 151 
 
 23 
 
 150 
 
 26 
 
 151 
 
 13 
 
 375 
 
 6 
 
 350 
 
 7 
 
 400 
 
 70 to 79 years. 
 
 73 
 
 506 
 
 64 
 
 490 
 
 25 
 
 447 
 
 39 
 
 523 
 
 9 
 
 664 
 
 5 
 
 826 
 
 4 
 
 533 
 
 80 years and over. 
 
 22 
 
 63 
 
 20 
 
 64 
 
 9 
 
 449 
 
 11 
 
 549 
 
 2 
 
 565 
 
 
 • • • • 
 
 2 
 
 909 
 
 Total . 
 
 1126 
 
 153 
 
 907 
 
 145 
 
 471 
 
 153 
 
 436 
 
 138 
 
 219 
 
 201 
 
 116 
 
 218 
 
 103 
 
 186 
 
 LOBAR PNEUMONIA. 
 
 Under 1 year. 
 
 39 
 
 263 
 
 31 
 
 241 
 
 18 
 
 273 
 
 13 
 
 207 
 
 8 
 
 407 
 
 2 
 
 209 
 
 6 
 
 593 
 
 1 to 4 years. 
 
 134 
 
 246 
 
 118 
 
 245 
 
 70 
 
 290 
 
 48 
 
 200 
 
 16 
 
 250 
 
 8 
 
 257 
 
 8 
 
 243 
 
 0 to 4 years. 
 
 173 
 
 249 
 
 149 
 
 244 
 
 88 
 
 286 
 
 61 
 
 141 
 
 24 
 
 287 
 
 10 
 
 246 
 
 14 
 
 325 
 
 5 to 9 years. 
 
 109 
 
 169 
 
 102 
 
 181 
 
 61 
 
 213 
 
 41 
 
 147 
 
 7 
 
 84 
 
 4 
 
 104 
 
 3 
 
 71 
 
 0 to 9 years. 
 
 282 
 
 211 
 
 251 
 
 214 
 
 149 
 
 251 
 
 102 
 
 176 
 
 31 
 
 189 
 
 14 
 
 177 
 
 17 
 
 200 
 
 10 to 19 years. 
 
 126 
 
 102 
 
 108 
 
 100 
 
 67 
 
 127 
 
 41 
 
 75 
 
 18 
 
 113 
 
 8 
 
 113 
 
 10 
 
 113 
 
 20 to 29 years. 
 
 136 
 
 94 
 
 93 
 
 78 
 
 61 
 
 104 
 
 32 
 
 53 
 
 43 
 
 166 
 
 26 
 
 213 
 
 17 
 
 125 
 
 30 to 39 years. 
 
 121 
 
 99 
 
 83 
 
 83 
 
 47 
 
 93 
 
 36 
 
 72 
 
 38 
 
 174 
 
 26 
 
 235 
 
 12 
 
 111 
 
 40 to 49 years. 
 
 90 
 
 97 
 
 65 
 
 85 
 
 44 
 
 115 
 
 21 
 
 54 
 
 25 
 
 161 
 
 14 
 
 169 
 
 11 
 
 151 
 
 50 to 59 years. 
 
 81 
 
 129 
 
 72 
 
 132 
 
 40 
 
 150 
 
 32 
 
 113 
 
 9 
 
 115 
 
 4 
 
 94 
 
 5 
 
 138 
 
 60 to 69 years. 
 
 84 
 
 233 
 
 74 
 
 227 
 
 34 
 
 222 
 
 40 
 
 232 
 
 10 
 
 289 
 
 5 
 
 292 
 
 5 
 
 285 
 
 70 to 79 years. 
 
 38 
 
 264 
 
 38 
 
 291 
 
 10 
 
 179 
 
 28 
 
 375 
 
 
 
 
 
 
 
 80 years and over. 
 
 11 
 
 32 
 
 11 
 
 35 
 
 3 
 
 150 
 
 8 
 
 399 
 
 
 
 
 
 
 
 Total . 
 
 969 
 
 132 
 
 795 
 
 127 
 
 455 
 
 148 
 
 340 
 
 107 
 
 174 
 
 160 
 
 97 
 
 182 
 
 77 
 
 139 
 
376 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 to the sixth decade, inclusive. The rate in the white ascends sharply in the 
 sixth, seventh, and eighth decades, and in the negro in the seventh decade. 
 In the latter there is little change in the level of the rate after the sixty- 
 ninth year, while in the white the rate falls sharply after the seventy-ninth 
 year of life; morbidity is considerably higher in the negro at every age- 
 period up to the eightieth year, but the difference is most marked between 
 the thirtieth and the fiftieth years. 
 
 Among whites the incidence of pneumonia is higher in males than in 
 females in every age-period except the fourth decade and after the sixty- 
 ninth year, while in the negro it is higher in males throughout life except 
 in the sixth, seventh, and eighth decades. This disparity between the rates for 
 males and females is greatest among whites in the first three decades and among 
 negroes in the third, fourth, and eighth decades. 
 
 It is notable that while the difference in incidence for broncho- and lobar 
 pneumonia in the population as a whole at all ages is not great, the rates being 
 153 and 138, respectively, the proportional distribution of morbidity rela¬ 
 tive to the different age-groupings varies widely. In both the rates of mor¬ 
 bidity are considerably higher in negroes than in whites and in males than 
 in females of both races. As with the mortality in 1920, the morbidity-rate 
 for broncho-pneumonia in 1921 is very high in the first decade. It recedes, 
 however, sharply in the second, falls still lower in the third, and remains rela¬ 
 tively low during the fourth and fifth decades. After the forty-ninth year the 
 rate of incidence rises steadily to a peak in the eighth decade and then falls 
 abruptly during the remainder of life. In every age period the rate is con¬ 
 siderably higher among negroes than among whites. Among the latter the 
 rate for males exceeds that for females in the first, second, sixth, and eighth 
 decades and eighty years and over, while in the third, fourth, and fifth decades 
 the case is reversed. Among negroes the rate of incidence is higher in males, 
 except in the sixth and seventh decades. 
 
 For lobar pneumonia in the population as a whole, from a relatively high 
 level for the first decade of life, the morbidity-rate falls markedly in the 
 second then slightly again to its lowest point in the third decade. There 
 is but little fluctuation in the rate in the 30 years between the twentieth and 
 the forty-ninth years of age. After the fiftieth year the rise in morbidity 
 is gradual and the peak is attained in the eighth decade, after which the 
 rate declines sharply. In general trend the course of the rate for whites 
 departs but slightly from that of the total rate. In the negro the course of 
 recorded morbidity shows distinct differences. Somewhat lower in the first 
 two decades of life than the rate for whites, it ascends abruptly in the third 
 decade to a relatively high level, which is maintained with little deviation 
 until the fiftieth year of life. The rate falls in the sixth decade to the 
 level of the second, but rises again in the seventh. No cases were reported 
 among negroes over the sixty-ninth year of age. 
 
 Among whites the rate is higher in males than in females until the sixty- 
 ninth year, after which the reverse is true. The rates for the two sexes, 
 however, follow in general the same trend. Among negroes the rate is 
 higher for males than for females in every decade except the first, sixth, and 
 seventh. But in the third, fourth, and fifth decades the trends of the two 
 
FEBRILE DISEASES 
 
 377 
 
 are quite different. The male rate runs to a high peak in the third and 
 fourth decades, and then falls in the fifth and sixth decades, to rise again in 
 the seventh. The rate for negro males is nearly as high in the fourth as in 
 the first decade. These irregularities in the course of the rates for negroes 
 are probably in large degree the result of inadequate case reporting. 
 
 In the main, however, the striking differences in the trends of the rates 
 for broncho- and lobar pneumonia observed in connection with mortality are 
 reflected in the morbidity-rates as well. In so far as may be judged from 
 this material, it would appear that in lobar pneumonia the risk of contract¬ 
 ing the disease varies hardly at all between the nineteenth and the forty- 
 ninth years, while the risk of dying from it rises progressively between the 
 twentieth and thirty-ninth years, remains unchanged between the fortieth 
 and forty-ninth years, and thereafter increases with much the same propor¬ 
 tion as does morbidity. With broncho-pneumonia, on the other hand, ex¬ 
 cept in the second decade of life, the risks of incidence and of death in the 
 various age-groups follow the same trend in all the age-groups. 
 
 On the whole, the trends of morbidity-rates specific for age, color, and 
 sex for total pneumonia, and for lobar and broncho-pneumonia separately, 
 in 1921 follow closely those of the corresponding rates for mortality in 
 1920. The agreement in respect to the variation with age of the qualities 
 which control resistance to lobar and broncho-pneumonia and the specific 
 differences in natural immunity of individuals toward these two kinds of 
 acute lung infection support the implications in these regards derived from 
 the study of mortality alone. 
 
 SUMMARY. 
 
 The curve for total annual mortality-rates from the acute inflammatory 
 affections of the respiratory tract (table 60, graph 17) is marked through¬ 
 out most of its course by rather wide fluctuations. Some of these are 
 short and cover only from one to three years, while others extend over a 
 long sweep of years. The first are particularly common before 1840, and 
 are usually associated with corresponding variations in the rates for each 
 member of the group. They are particularly wide for whooping-cough. The 
 second type occurs when, owing to the gradually diminishing importance 
 of the latter disease and the steadily rising rates for diphtheria and pneu¬ 
 monia, the curve for the total rates tends to grow smoother. 
 
 Two distant, though irregular, waves in the curve for the total rate appear 
 before 1840. The first, beginning in 1812, reached a peak with a rate of 449 
 in 1816, and declined to a low level with a rate of 95 in 1831. The second, 
 starting in 1832 and with its peak of 273 in 1833, subsided in 1840 to a rate 
 of 116. The next year the curve for the total rates again began to ascend and 
 by 1848 had reached 315. 
 
 From this level the departure was very slight until after 1875. By 1882 the 
 rate had reached 478, and from this point there was a gradual decline to 253 in 
 1889. Between 1891 and 1903 the total rate was almost constantly above 300 
 and in several years surpassed 375. Then there was a gradual descent to lower 
 levels, but never under 200, until 1918, when in connection with the influenza— 
 pneumonia epidemic and some increase of the whooping-cough rate, the total 
 
378 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 rate rose to 658. The next year, however, the rate fell to 222. After 1885, the 
 shape of the curve of the total rates was in ever-increasing degree determined 
 by the rates for pneumonia. 
 
 It is, however, from the curve of the rates as averaged for 5-year periods 
 (table 61, graph 18) that the clearest picture of the course of these affections 
 is obtained. Starting with a rate of 318 in 1812-1815 and declining slightly 
 by 1820, the total rate dropped decidedly in 1821-1825 to 171. Five years 
 later it had fallen to 152, the lowest level ever attained. This fall was due to 
 declines in the rates for each member of the group. From 1835 the total rate 
 ascended by gradual steps to 309 in 1851-1855. This change was brought 
 about entirely by increases in the rates for pneumonia and diphtheria; the 
 rate for whooping-cough was practically stationary. After falling slightly 
 during the next 10 years, due to a sharp decline in the diphtheria rate, the 
 total rate rose gradually to its highest level, 418, in 1881-1885. This was 
 associated with an almost unbroken rise in the pneumonia rate and a sudden 
 and great rise in that for diphtheria during the last 10 years. In 1881-1885 
 the rates for each of these two diseases stood almost at the same level, i. e., 
 about 200. By 1880, the rate for whooping-cough had declined conspicu¬ 
 ously, and in 1881-1885 was only 21. Due to an abrupt fall in the rates for 
 diphtheria and whooping-cough, which more than overbalanced the steady 
 rise in the pneumonia rate, the total rate declined to 319 in 1886-1890. Its 
 rise to 363 in 1891-1895 was owing entirely to the continued ascent in the 
 pneumonia rate. From this level the rate declined continuously to 244 in 
 1911-1915. During these 20 years the rates for all the members of the group 
 fell decidedly, though not always at the same time. Owing almost entirely to 
 a rise in the pneumonia rate, the total rate rebounded to 332 in 1916-1920. 
 The total rate, therefore, fell continuously and decidedly between 1812 and 
 1830 from a high to a very low level. During the succeeding 55 years the rate 
 rose to its highest peak in 1881-1885, and from this point declined, with but 
 one interruption, until 1911-1915. 
 
 From this detailed account of the behavior of this group of diseases, certain 
 important considerations are evident. No attempts at artificial interference 
 with the progress of pneumonia have ever been made in Baltimore. Such 
 attempts of this nature against whooping-cough as have been made during 
 the past 20 years have proven fruitless. It has been shown that coincidently 
 with the use of improved methods of treatment (intubation about 1890 and 
 antitoxin since 1897, particularly since 1900), the mortality-rate from diph¬ 
 theria has fallen markedly. Therefore, the courses run by pneumonia and 
 whooping-cough for 108 years and for diphtheria for 78 years reflect fairly accu¬ 
 rate pictures of their natural reaction on this population. Here is another clear- 
 cut example over a long period of the reaction of an organ system to its 
 most serious acute infective diseases. After a century of experiment, it ends 
 up as concerns the group as a whole no better than it began, i. e., with death- 
 rates at about the same level. Since their mortality-rates have differed widely 
 during this time, it is evident that either the lethal force of each or the char¬ 
 acter of the natural resistance of the population, or both, have varied not once 
 but several times. 
 
 How much these changes in the courses of mortality were due to variations 
 in the virulence of the organisms, to the differences in the resistance of the 
 
FEBRILE DISEASES 
 
 379 
 
 various race stocks present in the population at different times, to the changes 
 in the age distribution of those exposed, and to the modification in the 
 environment, it is difficult to estimate with accuracy. 
 
 Concerning one member of this group, whooping-cough, this question can 
 be answered with some degree of definitiveness. The lethal force of this 
 disease, after exhibiting a considerable accession between 1812 and 1820, had, 
 by 1825, sunk to its previous level, and from this time it varied only within 
 comparatively narrow limits until 1880. During this period of 68 years very 
 profound changes in the population and in the environment had occurred. 
 From 1880 to 1900, also a period of considerable changes in the environment, 
 its lethal force sank to a yet lower level, about which it has tended to stabilize, 
 in a population whose racial composition underwent notable changes. Since 
 1825, the mortality-rates of whooping-cough have varied for only a short 
 period between 1860 and 1870, directly with those of pneumonia, its most 
 important lethal complication. No variety of medical treatment has been 
 shown to influence either the duration or the severity of the disease. There¬ 
 fore, as it appears that the variations in the lethal capacity of whooping- 
 cough are not directly correlated with changes in population composition, 
 modifications of the environment, or medical treatment, the evidence at hand 
 goes to show that they must lie primarily in modifications in its specific cause. 
 From considerations already brought forward, it would appear that with 
 decrease in lethal force, the disease has made decided gains in invasive 
 capacity. 
 
 Under the same conditions, the course of mortality for diphtheria followed 
 very much the same course as whooping-cough until 1845. For the next 20 
 years, in association with very definite changes of both population and 
 environment, the lethal force of diphtheria increased markedly. In the 10 
 years from 1866 to 1875 the mortality sank decidedly, only, however, to rise 
 in the next 10 years to an unprecedented level. Its abrupt fall between 1885 
 and 1890, to a level held for the succeeding 10 years, during a period of con¬ 
 siderable change in the population composition, was as striking as the previous 
 rise. As intubation can hardly be held responsible for more than a small part 
 of the change in the mortality-rates during the last phase, the period of 
 untrammeled course for diphtheria may for practical purposes be taken as 88 
 years. As the course of this disease has often varied directly with changes in 
 the population composition and the environment, variations of its lethal force 
 can not be ascribed wholly to modifications in its causal agent. The fact that 
 diphtheria mortality-rates have varied widely from time to time (associated 
 often with the presence or absence of epidemics) in countries with fairly 
 homogeneous populations and in rural districts where population changes 
 of this type have been gradual or even absent and where environmental condi¬ 
 tions tend to remain constant, suggests that variability in the virulence of 
 B. diphtherice has been the chief cause of variations in the mortality-rates. 
 It is well established by laboratory observation and experiment that the 
 virulence of B. diphtherice often changes under the influence of a variety of 
 modifications of environment, but the conditions under which it is grown are 
 too highly artificial to warrant too close a comparison with what occurs under 
 natural conditions. 
 
 25 
 
380 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 With the acute pulmonary diseases, with their diversities of etiology and 
 pathology, the case is more complicated. Certain it is that having fallen to 
 a low level by 1830, the rate rose strikingly from 1845 to 1855, during a 
 period of rapid and fundamental changes in population and environment. 
 However, it fell as markedly during the next 10 years without any considerable 
 change in either. From 1865 to 1895 the progress of the mortality-rate was 
 steadily upward, and from 1895 to 1910 it was as steadily downward, in face 
 of decided population changes in both periods. With no particular changes 
 in the race composition of the population and greater changes in the environ¬ 
 ment that previous years had witnessed, the rate was stationary from 1910 
 to 1915, and then rose sharply in the last 5-year period. From this picture it 
 would appear that whatever the influence of other factors, the changes in the 
 mortality-rates from the pneumonia diseases are not independent of varia¬ 
 tions in the virulence of one or more of their causal agents. 
 
 Among the factors responsible for the fall in mortality from diphtheria 
 since 1880 are the decline in the proportion to the total population of age- 
 group 0 to 9 years and the striking decrease in the susceptibility of the negro 
 as compared with the white. Similarly, much of the decrease in the mortality 
 from whooping-cough since its high level in 1860-1870 is associated with a 
 decline in the proportional relations in the population of this same age-group 
 and of the negro, in whom the disease is peculiarly fatal. 
 
 With pneumonia the relation of changes in the age-groupings and of the 
 proportion of negroes to whites in the population to mortality is a much more 
 complex question, because of lack of knowledge of the relative frequency of 
 lobar and broncho-pneumonia in the past and because both forms of pneumonia 
 are particularly fatal in both extremes of life. Since 1850, the proportions of 
 individuals in the population in both early life, when mortality is high, and 
 between ages 10 and 39, when it is comparatively low, have declined, but that 
 above age 39, when mortality rapidly increases to old age, has risen markedly. 
 
 TUBERCULOSIS. 
 
 Under the title consumption, pulmonary tuberculosis appeared in the table 
 of interments in 1812 as an important cause of death, with 252 out of a total 
 of 1,184 deaths, or 21 per cent or over 1 in 5 of all deaths, and under one or 
 the other of these titles the disease can be followed in each subsequent year. 
 Under this rubric have been included in the present study also deaths assigned 
 to pulmonary hemorrhage and laryngeal tuberculosis. While it is probable 
 that, in the early days, the diagnosis of lethal pulmonary tuberculosis was 
 made with a fair degree of accuracy, particularly in cases of ordinary dura¬ 
 tion, it is likely that deaths classified under this rubric included some deaths 
 from chronic non-tuberculous pneumonia and empyema, tumors of the lungs 
 and of the mediastinal structures, and that some deaths, especially from the 
 acute types of pulmonary tuberculosis, were classified under other headings. 
 
 Under the heading “ other forms of tuberculosis” have been assembled 
 deaths attributed in the tables of interments to scrofula, Potts’s disease, 
 caries of the vertebras, disease of the hip and spine, white swelling, and tuber¬ 
 culous meningitis, until the adoption of the international classification in 
 1899 and, since that date, all deaths assigned to tuberculosis of other organs 
 
FEBRILE DISEASES 
 
 381 
 
 than the lungs and larynx. In the early years a considerable number of deaths 
 were attributed to scrofula. Of the total of 215 deaths credited in 1875 to 
 meningitis, cerebro-spinal meningitis, and tuberculous meningitis, 83 were 
 ascribed to the latter cause. It is likely that until 1899 many of the deaths 
 classified under dropsy of the head, hydrocephalus, convulsions, and marasmus 
 were really due to tuberculosis. There must have been a considerable number 
 of deaths due to generalized miliary tuberculosis and tuberculous peritonitis 
 classified under other headings. It seems certain, therefore, that throughout 
 the nineteenth century the total number of deaths due to “ other forms of 
 tuberculosis ” was much larger than the actual figures indicate. 
 
 The incentive that has come into existence during the past 20 or 25 years, 
 on account of the exclusive clauses in insurance policies of a certain type, to 
 conceal deaths from tuberculosis by reporting them under other rubrics, has 
 unquestionably resulted in willful falsification of the returns to a certain 
 extent. Typhoid fever, malaria, chronic bronchitis, and pneumonia have been 
 the chief rubrics of classification of such deaths. As a matter of fact, chronic 
 bronchitis since 1899 (table 60) is the only one of these rubrics to which any 
 considerable number of deaths from pulmonary tuberculosis could have been 
 credited. Were all the deaths from this cause since 1899 assigned to pul¬ 
 monary tuberculosis, which is by no means warranted, the annual rates for 
 the latter would be raised somewhat, but the general trend of the curve of 
 mortality would not be materially changed. Counterbalancing this source of 
 error, on the other hand, are to be taken into account the consistent efforts 
 put forth in the health department to obtain greater accuracy in the certifica¬ 
 tion and classification of causes of death, and the fact that newer methods of 
 diagnosis and better medical training have tended to render the diagnosis of 
 tuberculosis more certain. 
 
 The establishment of sanatoria in the last 14 years without the city limits 
 for the reception of cases of pulmonary tuberculosis has exerted in a very 
 direct way a decidedly favorable influence upon the official death-rates from 
 this affection. During the 8 years 1913 to 1920 there were in the three larger 
 sanatoria within the state (Sabillasville, Eudowood, and Jewish Home for 
 Consumptives) 811 deaths from pulmonary tuberculosis among patients sent 
 from Baltimore City. These individuals would have died within the city and 
 their deaths would have been recorded in the official figures for the latter had 
 these sanatoria not been in existence. When this number is added to the 
 total number of deaths from pulmonary tuberculosis recorded within the city 
 during these 8 years, it is evident that by this change of location for the act 
 of death the official figures for deaths from this affection have been made to 
 undergo a reduction of at least 9 per cent [811 -r- 9,764 (i. e., 8,953 + 811) 
 = 9.06 per cent]. In other words, by charging deaths of Baltimore citizens 
 temporarily domiciled for treatment in extra-urban sanatoria against the 
 counties in which the latter are situated, instead of against the city in which 
 they became ill and were registered as cases, a purely fictitious reduction of 
 9 per cent in the number of deaths from pulmonary tuberculosis in Baltimore 
 has resulted. As all of these 811 individuals were white, this apparent and 
 quite artificial decrease in the number of deaths in this race from pulmonary 
 tuberculosis in this period was 12.5 per cent (811 -f- 6,503 = 12.5 per cent) 
 (table 85). This practice has exerted a marked influence upon the death-rates 
 
382 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 for tuberculosis. These deaths thus transferred were not counterbalanced by 
 deaths of tuberculosis within the city of non-residents, which in 1917, a 
 typical year, was only 23, a number far less than the probable number of 
 deaths of citizens of Baltimore in places other than these 3 sanatoria. Indeed, 
 during the last 20 years considerable numbers of individuals with tuberculosis 
 who otherwise would have died in the city have moved to the nearby suburban 
 districts on the advice of physicians. 
 
 The annual mortality-rates for pulmonary, other forms, and all forms of 
 tuberculosis are given in table 78 and graph 21. The rates for pulmonary 
 tuberculosis often show rather wide fluctuations, not only from year to year, 
 but over terms of years. Starting with the unusually high rate of 616 in 
 1812, and falling below 500 in only 4 of the following 10 years, the rates fell 
 from 557 in 1821 to 278 in 1824. Reacting the next year to 416, they fell 
 gradually to 323 in 1829. Ascending to 437 in 1832, the rates had declined 
 to 298 in 1836, and after another short upward turn to 362 in 1838, they fell 
 to 297 in 1840. During the next 14 years the rates rose, except for a slight 
 recession in 1850, continuously to 506 in 1854. From this point, but with 
 some irregularity, they descended to 326 in 1867. With slight annual fluctua¬ 
 tions the rates again gradually rose to 381 in 1876, and then fell by gradual 
 steps to 273 in 1889. After a slight reaction to '292 in 1890, there was a 
 gradual decline during the following years to 197 in 1899: With a gradual 
 ascent to 257 in 1904, there was an irregular decline to 183 in 1915. Then 
 by even steps the rates rose to 206 in 1918, but fell to 143 in 1919 and to 128 in 
 1920. The annual rates for other forms of tuberculosis, while in general low, 
 varied rather widely between 1812 and 1874. In 1812, 1815, 1817, 1818, 
 1819, and 1829, no deaths were registered under the headings composing this 
 rubric. During the remaining years, the rates varied from the lowest, 1, in 
 1826 to the highest, 19, in 1822. Rates as high as 8, 10, 12, and 13 occurred 
 in a few years. In 1875, due very largely to the recognition of tuberculous 
 meningitis in the nosological classification, the rate jumped to 60. From 
 this date the rates declined gradually, but by irregular steps, to 20 in 1898. 
 The rate rose abruptly to 50 in 1899, and after registering 42 in 1900 and 
 46 in 1901, it fell to 22 in 1902. The rate ascended during the next 3 years, 
 and in 1905 stood at 39. It gradually fell to 28 in 1910. Reacting again to 
 39 in 1911, it fell continuously to 32 in 1917. Rising to 36 in 1918, the rate 
 fell to 30 in 1919 and to 23 in 1920. Since the striking rise in the rate for this 
 rubric in 1875, rates lower than 23 were attained in 1891, from 1893 to 1898, 
 inclusive, and in 1902. 
 
 Before 1875, for obvious reasons, the rates for all forms of tuberculosis were 
 but slightly higher than those for pulmonary tuberculosis. With the rise in the 
 former and the fall in the latter after this date the curves for the two grad¬ 
 ually separate. From the high level of 434 in 1876, the rate for all forms 
 declined to 259 in 1896, and after reacting to 285 in 1904, receded by gradual 
 steps to 214 in 1915. During the next 3 years the rate rose to 242 in 1918, 
 and fell precipitously to 173 in 1919 and to 151 in 1920. 
 
 A very clear idea of the course of tuberculosis in Baltimore is obtained from 
 study of death-rates for pulmonary, other forms, and all forms of the disease 
 averaged for 5- and 10-year periods (table 79, graphs 22 and 23). 
 
Table 78. — Number of deaths and rate of death, per 100,000 living inhabitants, from all forms of 
 tuberculosis, pulmonary tuberculosis, and other forms of tuberculosis, from 1812 to 1920, in¬ 
 clusive. 
 
 D = death. R = rate. 
 
 Year. 
 
 Tuberculosis. 
 
 Year. 
 
 Tuberculosis. 
 
 Year. 
 
 Tuberculosis. 
 
 All 
 
 forms. 
 
 
 Pul¬ 
 
 monary. 
 
 Other 
 
 forms. 
 
 All 
 
 forms. 
 
 Pul¬ 
 
 monary. 
 
 Other 
 
 forms. 
 
 All 
 
 forms. 
 
 Pul¬ 
 
 monary 
 
 Other 
 
 forms. 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 1812 
 
 
 252 
 
 616 
 
 252 
 
 616 
 
 
 
 1849 
 
 
 678 
 
 4 Of] 
 
 
 A1Q 
 
 in 
 
 fi 
 
 1885 
 
 
 138° 
 
 369 
 
 1284 
 
 343 
 
 98 
 
 29 
 
 1813 
 
 • • • • 
 
 219 
 
 512 
 
 218 
 
 509 
 
 ~ 
 
 ~~2 
 
 1850 
 
 
 589 
 
 359 
 
 581 
 
 354 
 
 8 
 
 o 
 
 5 
 
 1886 
 
 
 1319 
 
 345 
 
 1202 
 
 315 
 
 117 
 
 31 
 
 1814 
 
 • • • • 
 
 226 
 
 505 
 
 225 
 
 503 
 
 1 
 
 2 
 
 1851 
 
 .... 
 
 690 
 
 409 
 
 679 
 
 403 
 
 11 
 
 7 
 
 1887 
 
 .... 
 
 1224 
 
 314 
 
 1109 
 
 285 
 
 115 
 
 80 
 
 1815 
 
 • • • • 
 
 218 
 
 466 
 
 218 
 
 466 
 
 
 
 1852 
 
 .... 
 
 741 
 
 427 
 
 728 
 
 420 
 
 13 
 
 8 
 
 1888 
 
 .... 
 
 1306 
 
 311 
 
 1176 
 
 280 
 
 130 
 
 31 
 
 1816 
 
 • • . • 
 
 254 
 
 520 
 
 250 
 
 512 
 
 4 
 
 8 
 
 1853 
 
 
 910 
 
 510 
 
 893 
 
 501 
 
 17 
 
 10 
 
 1889 
 
 .... 
 
 1282 
 
 295 
 
 1168 
 
 273 
 
 114 
 
 26 
 
 1817 
 
 • • • • 
 
 239 
 
 469 
 
 239 
 
 469 
 
 
 
 1854 
 
 
 944 
 
 515 
 
 928 
 
 506 
 
 16 
 
 9 
 
 1890 
 
 .... 
 
 1402 
 
 323 
 
 1269 
 
 292 
 
 133 
 
 31 
 
 1818 
 
 • • • • 
 
 306 
 
 575 
 
 306 
 
 675 
 
 
 
 1855 
 
 .... 
 
 869 
 
 462 
 
 856 
 
 455 
 
 13 
 
 7 
 
 1891 
 
 .... 
 
 1192 
 
 270 
 
 1096 
 
 248 
 
 96 
 
 22 
 
 1819 
 
 • • • • 
 
 273 
 
 492 
 
 273 
 
 492 
 
 
 
 1856 
 
 ... 
 
 916 
 
 474 
 
 898 
 
 464 
 
 18 
 
 9 
 
 1892 
 
 .... 
 
 1261 
 
 281 
 
 1146 
 
 255 
 
 115 
 
 26 
 
 1820 
 
 • • • • 
 
 332 
 
 574 
 
 328 
 
 56? 
 
 4 
 
 7 
 
 1857 
 
 . . . „ 
 
 797 
 
 411 
 
 779 
 
 392 
 
 18 
 
 9 
 
 1893 
 
 .... 
 
 1213 
 
 266 
 
 1117 
 
 245 
 
 96 
 
 21 
 
 1821 
 
 • • • • 
 
 341 
 
 565 
 
 336 
 
 557 
 
 5 
 
 8 
 
 1858 
 
 .... 
 
 863 
 
 424 
 
 838 
 
 411 
 
 25 
 
 12 
 
 1894 
 
 .... 
 
 1231 
 
 265 
 
 1127 
 
 243 
 
 104 
 
 22 
 
 1822 
 
 • • • • 
 
 808 
 
 490 
 
 296 
 
 471 
 
 12 
 
 19 
 
 1859 
 
 .... 
 
 728 
 
 348 
 
 723 
 
 346 
 
 5 
 
 2 
 
 1895 
 
 .... 
 
 1247 
 
 265 
 
 1156 
 
 245 
 
 91 
 
 19 
 
 1823 
 
 • • • • 
 
 238 
 
 364 
 
 237 
 
 362 
 
 1 
 
 2 
 
 1860 
 
 .... 
 
 852 
 
 397 
 
 839 
 
 391 
 
 13 
 
 6 
 
 1896 
 
 .... 
 
 1242 
 
 259 
 
 1140 
 
 238 
 
 102 
 
 21 
 
 1824 
 
 • • • • 
 
 191 
 
 281 
 
 189 
 
 278 
 
 2 
 
 3 
 
 1861 
 
 .... 
 
 848 
 
 386 
 
 840 
 
 382 
 
 8 
 
 4 
 
 1897 
 
 .... 
 
 1150 
 
 237 
 
 1061 
 
 218 
 
 89 
 
 18 
 
 1825 
 
 • • • • 
 
 300 
 
 424 
 
 295 
 
 416 
 
 5 
 
 7 
 
 1862 
 
 .... 
 
 759 
 
 337 
 
 747 
 
 331 
 
 12 
 
 5 
 
 1898 
 
 .... 
 
 1252 
 
 254 
 
 1154 
 
 234 
 
 98 
 
 20 
 
 1826 
 
 • • • • 
 
 307 
 
 417 
 
 306 
 
 415 
 
 1 
 
 1 
 
 1863 
 
 .... 
 
 913 
 
 395 
 
 896 
 
 388 
 
 17 
 
 7 
 
 1899 
 
 .... 
 
 1236 
 
 247 
 
 987 
 
 197 
 
 249 
 
 60 
 
 1827 
 
 • • • • 
 
 272 
 
 355 
 
 267 
 
 349 
 
 5 
 
 7 
 
 1S64 
 
 .... 
 
 825 
 
 348 
 
 812 
 
 343 
 
 13 
 
 5 
 
 1900 
 
 ... 
 
 1289 
 
 254 
 
 1077 
 
 212 
 
 212 
 
 42 
 
 1828 
 
 • • • • 
 
 298 
 
 375 
 
 295 
 
 371 
 
 3 
 
 4 
 
 1865 
 
 .... 
 
 940 
 
 387 
 
 931 
 
 384 
 
 9 
 
 4 
 
 1901 
 
 
 1393 
 
 271 
 
 1158 
 
 225 
 
 235 
 
 46 
 
 1829 
 
 • • • • 
 
 267 
 
 323 
 
 267 
 
 323 
 
 
 
 1866 
 
 .... 
 
 984 
 
 396 
 
 977 
 
 393 
 
 7 
 
 3 
 
 1902 
 
 .... 
 
 1300 
 
 250 
 
 1188 
 
 228 
 
 112 
 
 22 
 
 1830 
 
 • • • • 
 
 335 
 
 391 
 
 332 
 
 388 
 
 3 
 
 4 
 
 1867 
 
 
 839 
 
 330 
 
 829 
 
 326 
 
 10 
 
 4 
 
 1903 
 
 .... 
 
 1378 
 
 261 
 
 1216 
 
 231 
 
 162 
 
 31 
 
 1831 
 
 • • • • 
 
 344 
 
 387 
 
 340 
 
 383 
 
 4 
 
 5 
 
 1868 
 
 
 903 
 
 347 
 
 885 
 
 340 
 
 18 
 
 7 
 
 1904 
 
 ■ • • • 
 
 1524 
 
 285 
 
 1375 
 
 257 
 
 149 
 
 28 
 
 1832 
 
 • • • • 
 
 408 
 
 443 
 
 403 
 
 437 
 
 5 
 
 5 
 
 1869 
 
 
 922 
 
 346 
 
 908 
 
 341 
 
 14 
 
 5 
 
 1905 
 
 .... 
 
 1471 
 
 272 
 
 1261 
 
 233 
 
 210 
 
 39 
 
 1833 
 
 • • • • 
 
 397 
 
 416 
 
 394 
 
 413 
 
 3 
 
 3 
 
 1870 
 
 
 1016 
 
 373 
 
 997 
 
 366 
 
 19 
 
 7 
 
 1906 
 
 .... 
 
 1492 
 
 273 
 
 1317 
 
 241 
 
 175 
 
 32 
 
 1834 
 
 .... 
 
 424 
 
 429 
 
 419 
 
 424 
 
 5 
 
 5 
 
 1871 
 
 
 940 
 
 337 
 
 922 
 
 331 
 
 18 
 
 6 
 
 1907 
 
 
 1495 
 
 270 
 
 1317 
 
 238 
 
 178 
 
 32 
 
 1835 
 
 . . . . 
 
 351 
 
 343 
 
 344 
 
 336 
 
 7 
 
 7 
 
 1872 
 
 
 990 
 
 347 
 
 970 
 
 340 
 
 20 
 
 7 
 
 1908 
 
 .... 
 
 1414 
 
 253 
 
 1250 
 
 223 
 
 164 
 
 29 
 
 1836 
 
 . , . . 
 
 318 
 
 300 
 
 316 
 
 298 
 
 2 
 
 2 
 
 1873 
 
 
 1135 
 
 389 
 
 1099 
 
 377 
 
 36 
 
 12 
 
 1909 
 
 
 1440 
 
 254 
 
 1273 
 
 225 
 
 167 
 
 80 
 
 1837 
 
 . , . . 
 
 408 
 
 372 
 
 396 
 
 361 
 
 12 
 
 ii 
 
 1874 
 
 . . . . 
 
 1147 
 
 385 
 
 1107 
 
 371 
 
 40 
 
 13 
 
 1910 
 
 
 1396 
 
 244 
 
 1234 
 
 216 
 
 162 
 
 28 
 
 1838 
 
 • . . . 
 
 421 
 
 371 
 
 410 
 
 362 
 
 11 
 
 10 
 
 1875 
 
 .... 
 
 1243 
 
 408 
 
 1061 
 
 348 
 
 182 
 
 60 
 
 1911 
 
 
 1388 
 
 240 
 
 1165 
 
 201 
 
 223 
 
 39 
 
 1839 
 
 . . . , 
 
 400 
 
 342 
 
 397 
 
 339 
 
 3 
 
 3 
 
 1876 
 
 .... 
 
 1350 
 
 434 
 
 1186 
 
 381 
 
 164 
 
 53 
 
 1912 
 
 
 1393 
 
 238 
 
 1189 
 
 204 
 
 204 
 
 35 
 
 1840 
 
 . . . . 
 
 367 
 
 303 
 
 359 
 
 297 
 
 6 
 
 7 
 
 1877 
 
 ... 
 
 1285 
 
 404 
 
 1104 
 
 347 
 
 181 
 
 57 
 
 1913 
 
 
 1341 
 
 227 
 
 1138 
 
 193 
 
 203 
 
 34 
 
 1841 
 
 . , . . 
 
 456 
 
 365 
 
 450 
 
 360 
 
 6 
 
 5 
 
 1878 
 
 
 1346 
 
 414 
 
 1150 
 
 354 
 
 196 
 
 60 
 
 1914 
 
 
 1344 
 
 226 
 
 1145 
 
 192 
 
 199 
 
 33 
 
 1842 
 
 . . . , 
 
 486 
 
 377 
 
 480 
 
 372 
 
 6 
 
 5 
 
 1879 
 
 
 1328 
 
 400 
 
 1184 
 
 351 
 
 144 
 
 43 
 
 1915 
 
 
 1290 
 
 214 
 
 1098 
 
 183 
 
 192 
 
 32 
 
 1843 
 
 . . . . 
 
 486 
 
 365 
 
 483 
 
 363 
 
 3 
 
 2 
 
 1880 
 
 • • • • 
 
 1413 
 
 417 
 
 1243 
 
 367 
 
 170 
 
 50 
 
 1916 
 
 
 1321 
 
 218 
 
 1121 
 
 185 
 
 200 
 
 33 
 
 1844 
 
 . , . , 
 
 513 
 
 374 
 
 510 
 
 372 
 
 3 
 
 2 
 
 1881 
 
 • • • • 
 
 1384 
 
 400 
 
 1227 
 
 355 
 
 157 
 
 45 
 
 1917 
 
 « • • • 
 
 1407 
 
 230 
 
 1213 
 
 198 
 
 194 
 
 32 
 
 1845 
 
 .... 
 
 530 
 
 375 
 
 525 
 
 371 
 
 5 
 
 4 
 
 1882 
 
 
 1379 
 
 391 
 
 1235 
 
 350 
 
 144 
 
 41 
 
 1918 
 
 
 1493 
 
 242 
 
 1273 
 
 206 
 
 220 
 
 £6 
 
 1846 
 
 . . . . 
 
 559 
 
 383 
 
 648 
 
 376 
 
 11 
 
 8 
 
 1883 
 
 .... 
 
 1432 
 
 398 
 
 1300 
 
 361 
 
 132 
 
 37 
 
 1919 
 
 
 1245 
 
 173 
 
 1029 
 
 143 
 
 216 
 
 30 
 
 1847 
 
 .... 
 
 593 
 
 395 
 
 590 
 
 393 
 
 3 
 
 2 
 
 1884 
 
 
 1281 
 
 349 
 
 1143 
 
 311 
 
 138 
 
 38 
 
 1920 
 
 
 1107 
 
 151 
 
 936 
 
 128 
 
 171 
 
 23 
 
 1848 
 
 .... 
 
 629 
 
 407 
 
 621 
 
 401 
 
 8 
 
 5 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Graph 21 (from table 78). Annual crude mortality rates from all forms, 
 pulmonary, and other forms of tuberculosis, from 1812 to 1920 inclusive. 
 
 (383) 
 
384 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 Considering first the rates averaged for 5-year periods, it will be noted 
 that for all forms and for pulmonary tuberculosis, owing to the relatively 
 very small contribution to the total made by other forms until 1875, the two 
 curves, running a parallel course, closely approximate each other from 1812 
 to 1875. For the next 10 years, owing to a high peak during this period for 
 other forms, the curve for all forms shows a correspondingly sharp rise, 
 while that for pulmonary tuberculosis is almost smooth. After 1885, the 
 descent in both curves is rapid and almost parallel, until 1900. Remaining 
 practically stationary at 525 between 1812 and 1820, the averaged rate for 
 all forms fell to 425 in 1825 and to 372 in 1830. For the period ending in 
 1835 the rate rose to 403, but for the succeeding 5 years fell to 338. Rising 
 steadily for the next 15 years to 465 between 1851 and 1855, the rate declined 
 by gradual steps to 358 between 1866 and 1870. An ascent during the next 
 
 Table 79 .—Average rate of death, per 100,000 living inhabitants, by 5- and 10-year 
 periods, from all forms of tuberculosis, pulmonary tuberculosis, and other forms of 
 tuberculosis, from 1812 to 1920, inclusive. 
 
 Periods. 
 
 All 
 
 forms. 
 
 Pul¬ 
 
 monary. 
 
 Other 
 
 forms. 
 
 
 Periods. 
 
 All 
 
 forms. 
 
 Pul¬ 
 
 monary. 
 
 Other 
 
 forms. 
 
 By 5-year 
 periods. 
 
 By 10 year 
 periods. 
 
 By 5-year 
 periods. 
 
 By 10-year 
 periods. 
 
 By 5-year 
 periods. 
 
 By 10-year 
 periods. 
 
 By 5-year 
 
 periods. 
 
 By 10-year 
 
 periods. 
 
 By 5-year 
 
 periods. 
 
 By 10-year 
 
 periods. 
 
 By 5-year 
 
 periods. 
 
 By 10-year 
 
 periods. 
 
 1812-15 . 
 
 525 
 
 
 524 
 
 
 1 
 
 
 
 1866-70 . 
 
 358 
 
 364 
 
 353 
 
 359 
 
 5 
 
 5 
 
 1816-20 . 
 
 526 
 
 526 
 
 523 
 
 523 
 
 3 
 
 2 
 
 
 1871-75 . 
 
 373 
 
 • • • 
 
 353 
 
 • • • 
 
 20 
 
 • • • 
 
 1821-25 . 
 
 425 
 
 • • • 
 
 417 
 
 • • • 
 
 8 
 
 • • • 
 
 
 1876-80 . 
 
 414 
 
 394 
 
 360 
 
 357 
 
 53 
 
 36 
 
 1826-30 . 
 
 372 
 
 399 
 
 369 
 
 393 
 
 3 
 
 5 
 
 
 1881-85 . 
 
 382 
 
 • • • 
 
 344 
 
 • • • 
 
 38 
 
 • • • 
 
 1831-35 . 
 
 403 
 
 • • • 
 
 398 
 
 • • • 
 
 5 
 
 • • • 
 
 
 1886-90 . 
 
 318 
 
 350 
 
 289 
 
 317 
 
 30 
 
 34 
 
 1836-40 . 
 
 338 
 
 371 
 
 331 
 
 365 
 
 6 
 
 6 
 
 
 1891-95 . 
 
 269 
 
 • • • 
 
 247 
 
 • • • 
 
 22 
 
 • • • 
 
 1841-45 . 
 
 371 
 
 • • • 
 
 368 
 
 • • • 
 
 3 
 
 • • • 
 
 
 1896-1900 . 
 
 250 
 
 260 
 
 220 
 
 234 
 
 30 
 
 26 
 
 1846-50 . 
 
 394 
 
 382 
 
 389 
 
 378 
 
 5 
 
 4 
 
 
 1901-05 . 
 
 268 
 
 • • • 
 
 235 
 
 • • • 
 
 33 
 
 • • • 
 
 1851-55 . 
 
 465 
 
 • • • 
 
 457 
 
 • • • 
 
 8 
 
 • • • 
 
 
 1906-10 . 
 
 259 
 
 263 
 
 228 
 
 232 
 
 30 
 
 32 
 
 1856-60 . 
 
 411 
 
 438 
 
 401 
 
 429 
 
 8 
 
 8 
 
 
 1911-15 . 
 
 229 
 
 • • • 
 
 195 
 
 • • • 
 
 35 
 
 • • • 
 
 1861-65 . 
 
 371 
 
 ... 
 
 365 
 
 • • • 
 
 5 
 
 • • . 
 
 
 1916-20 . 
 
 203 
 
 216 
 
 172 
 
 183 
 
 31 
 
 33 
 
 10 years culminated in an average rate of 414 in the 5-year period ending in 
 1880. From this level the averaged rates declined uninterruptedly to 250 in 
 1896-1900. After a slight reaction to 268 in 1901-1905, the rates declined 
 gradually to 203 in 1916-1920. 
 
 The death-rate for pulmonary tuberculosis was practically constant at 524 
 from 1812 to 1820, when, by an abrupt descent in 10 years, it fell 33 per 
 cent to 369. Rising to a rate of 398 in 1831-1835, it descended by 1840 to 
 the relatively low rate of 331. From this point there was a wave covering 
 30 years, with its peak in 1855 with a rate of 457, and falling off in 1866- 
 1870 to a rate of 353, from which it hardly deviated during the following 15 
 years. Between 1881 and 1885 there was a minor drop in the averaged rate, 
 and between the latter date and 1900 the rate fell to 220, to rise again in 
 1901-1905 to 235. In 1906-1910 it had fallen to 228, and during the last 
 10 years the fall was again steep, but not so abrupt as between 1885 and 
 1900, to 172. 
 
 After 1885 the curve of the rates for all forms, brought up by the increase 
 in the rates for other forms since 1875, follows the same general course of 
 
FEBRILE DISEASES 
 
 385 
 
 Graph 22 (from table 79). Crude mortality rates from all forms, pul¬ 
 monary, and other forms of tuberculosis, averaged by 5-year periods, from 
 1812 to 1920, inclusive. 
 
 Graph 23 (from table 79). Crude mortality rates from all forms, pul¬ 
 monary, and other forms of tuberculosis, averaged by 10-year periods, from 
 1812 to 1920, inclusive. 
 
386 PUBLIC HEALTH ADMINISTRATION", ETC., IN BALTIMORE 
 
 that for pulmonary tuberculosis. Because the rate for other forms contributes 
 such a relatively small quota to the total rate, and since 1900 it has stabilized 
 around a relatively low level, its effect upon the rate for all forms is readily 
 absorbed. During the last 20 years it has averaged about 30. 
 
 Turning to the rates averaged for 10-year periods, the curves are of course 
 much smoother. The low point for the first wave for pulmonary tuberculosis 
 is between 1831 and 1840, a drop to 365 from a rate of 523 in 1812-1820. 
 By 1860 the rate had ascended to 429. Following a fall between 1861 and 
 1870 to 359, the averaged rate remained nearly constant during the next 
 decade, after which it fell steadily during 1891-1900 to 234. Falling but 
 slightly during the next 10 years, it dropped to 183 for the decade 1911-1920. 
 
 Viewed from any standpoint, it is very clear from these sets of curves 
 that, on the whole, the death-rate for tuberculosis in the local population has 
 undergone a remarkable drop between 1812 and 1920. The dotted lines on 
 graph 21 indicate the difference in the course of the curves made by correcting 
 the official rates by the “ true rates” (table 85) calculated after the addition 
 of the deaths from pulmonary tuberculosis at sanatoria to figures for the 
 deaths occurring within the city. From these it is clear that the descent in 
 the rates that had occurred since 1905 is by no means as great as would appear 
 from the uncorrected figures, and that even from the official rates the angle 
 of fall in this period is by no means so acute as those of the decided falls 
 which began after 1820 and 1885. 
 
 The influence of race, as determined by color, upon the death-rates from 
 tuberculosis has been conspicuous. The figures for the annual number of 
 deaths among whites and negroes are available for pulmonary tuberculosis 
 since 1875 and for other forms of tuberculosis as a group since 1900 (table 
 "80 and graph 24). The rates for negroes under both of these headings and in 
 
 Graph 24 (from table 80). Annual mortality rates, specific for color and sex, 
 from pulmonary tuberculosis from 1875 to 1920, inclusive. 
 
FEBRILE DISEASES 
 
 387 
 
 Table SO .—Number of deaths and rate of death, per 100,000 living inhabitants, from 
 pulmonary tuberculosis, other forms of tuberculosis, and all forms of tuberculosis, 
 from 1876 to 1920, inclusive, according to color and sex. 
 
 PULMONARY TUBERCULOSIS. 
 
 D = death. R = rate. 
 
 
 
 
 White. 
 
 Colored. 
 
 
 
 
 tax. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Year. 
 
 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 1875 
 
 • • 
 
 1040 
 
 341 
 
 767 
 
 298 
 
 364 
 
 292 
 
 403 
 
 303 
 
 273 
 
 580 
 
 124 
 
 627 
 
 149 
 
 546 
 
 1876 
 
 • • 
 
 1167 
 
 375 
 
 837 
 
 318 
 
 398 
 
 313 
 
 439 
 
 323 
 
 330 
 
 687 
 
 143 
 
 707 
 
 187 
 
 673 
 
 1877 
 
 • • 
 
 1094 
 
 344 
 
 771 
 
 287 
 
 358 
 
 275 
 
 413 
 
 297 
 
 323 
 
 659 
 
 126 
 
 608 
 
 197 
 
 696 
 
 1878 
 
 • • 
 
 1127 
 
 347 
 
 803 
 
 292 
 
 386 
 
 291 
 
 417 
 
 294 
 
 324 
 
 647 
 
 125 
 
 589 
 
 199 
 
 690 
 
 1879 
 
 • • 
 
 1162 
 
 350 
 
 822 
 
 293 
 
 406 
 
 299 
 
 416 
 
 287 
 
 340 
 
 666 
 
 150 
 
 691 
 
 190 
 
 647 
 
 1880 
 
 • • 
 
 1221 
 
 361 
 
 878 
 
 306 
 
 416 
 
 300 
 
 462 
 
 312 
 
 343 
 
 658 
 
 154 
 
 693 
 
 189 
 
 632 
 
 1881 
 
 • • 
 
 1206 
 
 349 
 
 839 
 
 287 
 
 376 
 
 266 
 
 463 
 
 306 
 
 367 
 
 691 
 
 170 
 
 748 
 
 197 
 
 647 
 
 1882 
 
 • • 
 
 1217 
 
 345 
 
 849 
 
 284 
 
 406 
 
 281 
 
 443 
 
 287 
 
 368 
 
 679 
 
 168 
 
 723 
 
 200 
 
 646 
 
 1883 
 
 • • 
 
 1272 
 
 353 
 
 881 
 
 289 
 
 411 
 
 279 
 
 470 
 
 299 
 
 391 
 
 707 
 
 171 
 
 719 
 
 220 
 
 698 
 
 1884 
 
 • • 
 
 1126 
 
 311 
 
 792 
 
 255 
 
 402 
 
 268 
 
 390 
 
 243 
 
 334 
 
 592 
 
 150 
 
 617 
 
 184 
 
 574 
 
 1885 
 
 • • 
 
 1270 
 
 339 
 
 888 
 
 280 
 
 430 
 
 281 
 
 458 
 
 280 
 
 382 
 
 664 
 
 192 
 
 772 
 
 190 
 
 582 
 
 1886 
 
 • • 
 
 1204 
 
 315 
 
 843 
 
 261 
 
 416 
 
 266 
 
 427 
 
 256 
 
 361 
 
 616 
 
 144 
 
 567 
 
 217 
 
 654 
 
 1887 
 
 • • 
 
 1100 
 
 283 
 
 751 
 
 228 
 
 373 
 
 234 
 
 378 
 
 222 
 
 349 
 
 584 
 
 161 
 
 620 
 
 188 
 
 557 
 
 1888 
 
 • • 
 
 1165 
 
 278 
 
 810 
 
 228 
 
 403 
 
 237 
 
 407 
 
 219 
 
 355 
 
 557 
 
 171 
 
 613 
 
 184 
 
 514 
 
 1889 
 
 • • 
 
 1147 
 
 269 
 
 827 
 
 228 
 
 412 
 
 238 
 
 415 
 
 220 
 
 320 
 
 493 
 
 145 
 
 510 
 
 175 
 
 481 
 
 1890 
 
 • • 
 
 1249 
 
 287 
 
 914 
 
 248 
 
 469 
 
 266 
 
 445 
 
 232 
 
 335 
 
 508 
 
 162 
 
 559 
 
 173 
 
 468 
 
 1891 
 
 • • 
 
 1073 
 
 243 
 
 755 
 
 201 
 
 396 
 
 220 
 
 359 
 
 184 
 
 318 
 
 474 
 
 162 
 
 548 
 
 156 
 
 415 
 
 1892 
 
 • • 
 
 1127 
 
 251 
 
 780 
 
 205 
 
 388 
 
 212 
 
 392 
 
 198 
 
 347 
 
 508 
 
 173 
 
 575 
 
 174 
 
 455 
 
 1893 
 
 • • 
 
 1099 
 
 241 
 
 767 
 
 198 
 
 390 
 
 210 
 
 377 
 
 187 
 
 332 
 
 478 
 
 161 
 
 525 
 
 171 
 
 441 
 
 1894 
 
 • • 
 
 1106 
 
 238 
 
 766 
 
 195 
 
 405 
 
 214 
 
 361 
 
 177 
 
 340 
 
 482 
 
 154 
 
 493 
 
 186 
 
 472 
 
 1895 
 
 • • 
 
 1141 
 
 242 
 
 794 
 
 199 
 
 386 
 
 201 
 
 408 
 
 197 
 
 347 
 
 483 
 
 190 
 
 597 
 
 157 
 
 392 
 
 1896 
 
 • • 
 
 1122 
 
 234 
 
 771 
 
 190 
 
 429 
 
 219 
 
 342 
 
 163 
 
 351 
 
 481 
 
 188 
 
 581 
 
 163 
 
 401 
 
 1897 
 
 • • 
 
 1047 
 
 216 
 
 731 
 
 178 
 
 411 
 
 207 
 
 320 
 
 150 
 
 316 
 
 426 
 
 161 
 
 489 
 
 155 
 
 376 
 
 1898 
 
 • • 
 
 1061 
 
 215 
 
 731 
 
 175 
 
 385 
 
 191 
 
 346 
 
 160 
 
 330 
 
 438 
 
 179 
 
 534 
 
 151 
 
 361 
 
 1899 
 
 • • 
 
 987 
 
 197 
 
 666 
 
 157 
 
 365 
 
 178 
 
 301 
 
 138 
 
 321 
 
 419 
 
 166 
 
 487 
 
 155 
 
 365 
 
 1900 
 
 • • 
 
 1077 
 
 212 
 
 739 
 
 172 
 
 401 
 
 193 
 
 338 
 
 153 
 
 338 
 
 435 
 
 149 
 
 430 
 
 189 
 
 439 
 
 1901 
 
 • • 
 
 1158 
 
 225 
 
 797 
 
 183 
 
 442 
 
 210 
 
 355 
 
 158 
 
 361 
 
 457 
 
 189 
 
 536 
 
 172 
 
 394 
 
 1902 
 
 # # 
 
 1188 
 
 228 
 
 807 
 
 183 
 
 456 
 
 213 
 
 351 
 
 155 
 
 381 
 
 475 
 
 202 
 
 563 
 
 179 
 
 404 
 
 1903 
 
 • • 
 
 1216 
 
 231 
 
 837 
 
 188 
 
 457 
 
 211 
 
 380 
 
 166 
 
 379 
 
 466 
 
 201 
 
 551 
 
 178 
 
 397 
 
 1904 
 
 • • 
 
 1375 
 
 257 
 
 937 
 
 207 
 
 520 
 
 237 
 
 417 
 
 180 
 
 438 
 
 531 
 
 236 
 
 637 
 
 202 
 
 444 
 
 1905 
 
 • • 
 
 1261 
 
 233 
 
 833 
 
 182 
 
 471 
 
 212 
 
 362 
 
 154 
 
 428 
 
 511 
 
 229 
 
 609 
 
 199 
 
 432 
 
 1906 
 
 • • 
 
 1317 
 
 241 
 
 899 
 
 194 
 
 517 
 
 229 
 
 382 
 
 161 
 
 418 
 
 492 
 
 214 
 
 560 
 
 204 
 
 437 
 
 1907 
 
 • • 
 
 1317 
 
 238 
 
 879 
 
 188 
 
 484 
 
 212 
 
 395 
 
 165 
 
 438 
 
 509 
 
 227 
 
 585 
 
 211 
 
 446 
 
 1908 
 
 • • 
 
 1250 
 
 223 
 
 833 
 
 176 
 
 498 
 
 216 
 
 335 
 
 139 
 
 417 
 
 478 
 
 220 
 
 558 
 
 197 
 
 411 
 
 1909 
 
 • • 
 
 1273 
 
 225 
 
 815 
 
 171 
 
 460 
 
 197 
 
 355 
 
 146 
 
 458 
 
 518 
 
 258 
 
 645 
 
 200 
 
 413 
 
 1910 
 
 • • 
 
 1234 
 
 216 
 
 791 
 
 164 
 
 452 
 
 191 
 
 339 
 
 138 
 
 443 
 
 494 
 
 228 
 
 562 
 
 215 
 
 438 
 
 1911 
 
 • • 
 
 1165 
 
 201 
 
 733 
 
 150 
 
 437 
 
 183 
 
 296 
 
 119 
 
 432 
 
 475 
 
 235 
 
 570 
 
 197 
 
 397 
 
 1912 
 
 • • 
 
 1189 
 
 204 
 
 771 
 
 157 
 
 459 
 
 190 
 
 312 
 
 125 
 
 418 
 
 454 
 
 224 
 
 536 
 
 194 
 
 386 
 
 1913 
 
 • • 
 
 1138 
 
 193 
 
 743 
 
 150 
 
 411 
 
 168 
 
 332 
 
 132 
 
 395 
 
 424 
 
 211 
 
 498 
 
 184 
 
 362 
 
 1914 
 
 • • 
 
 1145 
 
 192 
 
 745 
 
 149 
 
 467 
 
 189 
 
 278 
 
 109 
 
 400 
 
 424 
 
 215 
 
 500 
 
 185 
 
 360 
 
 1915 
 
 • • 
 
 1098 
 
 183 
 
 673 
 
 133 
 
 416 
 
 167 
 
 257 
 
 100 
 
 425 
 
 445 
 
 237 
 
 544 
 
 188 
 
 362 
 
 1916 
 
 • • 
 
 1121 
 
 185 
 
 700 
 
 137 
 
 422 
 
 167 
 
 278 
 
 108 
 
 421 
 
 435 
 
 234 
 
 530 
 
 187 
 
 356 
 
 1917 
 
 • • 
 
 1213 
 
 198 
 
 730 
 
 142 
 
 453 
 
 178 
 
 277 
 
 107 
 
 483 
 
 494 
 
 281 
 
 628 
 
 202 
 
 380 
 
 1918 
 
 • • 
 
 1273 
 
 206 
 
 815 
 
 157 
 
 508 
 
 198 
 
 307 
 
 117 
 
 458 
 
 463 
 
 235 
 
 518 
 
 223 
 
 415 
 
 1919 
 
 • • 
 
 1029 
 
 143 
 
 670 
 
 109 
 
 388 
 
 126 
 
 282 
 
 91 
 
 359 
 
 344 
 
 195 
 
 407 
 
 164 
 
 291 
 
 1920 
 
 • • 
 
 936 
 
 128 
 
 616 
 
 99 
 
 335 
 
 109 
 
 281 
 
 89 
 
 320 
 
 294 
 
 141 
 
 265 
 
 179 
 
 323 
 
388 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 Table SO .—Number of deaths and rate of death, per 100,000 living inhabitants, from 
 
 pulmonary tuberculosis, etc j—Continued. 
 
 ALL FORMS TUBERCULOSIS. 
 
 
 
 
 White. 
 
 Colored. 
 
 
 
 JL Oldl* 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Year. 
 
 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 1900 
 
 • • 
 
 1289 
 
 254 
 
 869 
 
 202 
 
 474 
 
 228 
 
 395 
 
 178 
 
 420 
 
 540 
 
 188 
 
 542 
 
 232 
 
 539 
 
 1901 
 
 • • 
 
 1393 
 
 271 
 
 945 
 
 217 
 
 519 
 
 246 
 
 426 
 
 190 
 
 448 
 
 567 
 
 236 
 
 669 
 
 212 
 
 485 
 
 1902 
 
 • • 
 
 1300 
 
 250 
 
 891 
 
 202 
 
 499 
 
 223 
 
 392 
 
 173 
 
 409 
 
 510 
 
 220 
 
 613 
 
 189 
 
 427 
 
 1903 
 
 • • 
 
 1378 
 
 261 
 
 940 
 
 211 
 
 514 
 
 237 
 
 426 
 
 186 
 
 438 
 
 539 
 
 232 
 
 636 
 
 206 
 
 459 
 
 1904 
 
 • • 
 
 1524 
 
 285 
 
 1044 
 
 231 
 
 572 
 
 260 
 
 472 
 
 204 
 
 480 
 
 582 
 
 258 
 
 697 
 
 222 
 
 488 
 
 1905 
 
 • • 
 
 1471 
 
 272 
 
 972 
 
 213 
 
 542 
 
 244 
 
 430 
 
 183 
 
 499 
 
 596 
 
 261 
 
 694 
 
 238 
 
 516 
 
 1906 
 
 • • 
 
 1492 
 
 273 
 
 1012 
 
 219 
 
 581 
 
 258 
 
 431 
 
 182 
 
 480 
 
 565 
 
 250 
 
 654 
 
 230 
 
 493 
 
 1907 
 
 • • 
 
 1495 
 
 270 
 
 987 
 
 211 
 
 544 
 
 238 
 
 443 
 
 185 
 
 508 
 
 590 
 
 269 
 
 693 
 
 239 
 
 505 
 
 1908 
 
 • • 
 
 1414 
 
 253 
 
 951 
 
 201 
 
 564 
 
 244 
 
 387 
 
 160 
 
 463 
 
 530 
 
 244 
 
 619 
 
 219 
 
 457 
 
 1909 
 
 • • 
 
 1440 
 
 254 
 
 932 
 
 195 
 
 524 
 
 224 
 
 408 
 
 167 
 
 508 
 
 574 
 
 281 
 
 702 
 
 227 
 
 468 
 
 1910 
 
 • • 
 
 1396 
 
 244 
 
 902 
 
 187 
 
 509 
 
 215 
 
 393 
 
 160 
 
 494 
 
 551 
 
 257 
 
 633 
 
 237 
 
 483 
 
 1911 
 
 • • 
 
 1388 
 
 240 
 
 874 
 
 179 
 
 518 
 
 217 
 
 356 
 
 143 
 
 514 
 
 566 
 
 280 
 
 680 
 
 234 
 
 471 
 
 1912 
 
 • • 
 
 1393 
 
 238 
 
 900 
 
 183 
 
 531 
 
 220 
 
 369 
 
 147 
 
 493 
 
 536 
 
 268 
 
 641 
 
 225 
 
 448 
 
 1913 
 
 • • 
 
 1341 
 
 227 
 
 868 
 
 175 
 
 472 
 
 193 
 
 396 
 
 157 
 
 473 
 
 507 
 
 250 
 
 490 
 
 223 
 
 439 
 
 1914 
 
 • • 
 
 1344 
 
 226 
 
 854 
 
 170 
 
 530 
 
 215 
 
 324 
 
 127 
 
 490 
 
 519 
 
 265 
 
 617 
 
 225 
 
 438 
 
 1915 
 
 • • 
 
 1291 
 
 215 
 
 798 
 
 158 
 
 482 
 
 193 
 
 316 
 
 123 
 
 493 
 
 516 
 
 283 
 
 650 
 
 210 
 
 404 
 
 1916 
 
 • • 
 
 1321 
 
 218 
 
 807 
 
 158 
 
 484 
 
 192 
 
 323 
 
 125 
 
 514 
 
 531 
 
 287 
 
 650 
 
 227 
 
 432 
 
 1917 
 
 • • 
 
 1407 
 
 230 
 
 858 
 
 167 
 
 522 
 
 205 
 
 336 
 
 129 
 
 549 
 
 561 
 
 317 
 
 709 
 
 232 
 
 437 
 
 1918 
 
 • • 
 
 1493 
 
 242 
 
 941 
 
 181 
 
 579 
 
 225 
 
 362 
 
 138 
 
 552 
 
 558 
 
 292 
 
 644 
 
 260 
 
 484 
 
 1919 
 
 • • 
 
 1245 
 
 173 
 
 802 
 
 130 
 
 456 
 
 148 
 
 346 
 
 112 
 
 443 
 
 425 
 
 243 
 
 508 
 
 200 
 
 355 
 
 1920 
 
 • • 
 
 1107 
 
 151 
 
 715 
 
 114 
 
 388 
 
 126 
 
 327 
 
 103 
 
 392 
 
 360 
 
 181 
 
 340 
 
 211 
 
 380 
 
 OTHER FORMS TUBERCULOSIS. 
 
 1900 .. 
 
 212 
 
 42 
 
 130 
 
 30 
 
 73 
 
 35 
 
 57 
 
 26 
 
 82 
 
 105 
 
 39 
 
 112 
 
 43 
 
 100 
 
 1901 .. 
 
 235 
 
 46 
 
 148 
 
 34 
 
 77 
 
 37 
 
 71 
 
 32 
 
 87 
 
 110 
 
 47 
 
 133 
 
 40 
 
 92 
 
 1902 .. 
 
 112 
 
 22 
 
 84 
 
 19 
 
 43 
 
 20 
 
 41 
 
 18 
 
 28 
 
 35 
 
 18 
 
 50 
 
 10 
 
 23 
 
 1903 .. 
 
 162 
 
 31 
 
 103 
 
 23 
 
 57 
 
 26 
 
 46 
 
 20 
 
 59 
 
 73 
 
 31 
 
 85 
 
 28 
 
 62 
 
 1904 .. 
 
 149 
 
 28 
 
 107 
 
 24 
 
 52 
 
 24 
 
 55 
 
 24 
 
 42 
 
 51 
 
 22 
 
 59 
 
 20 
 
 44 
 
 1905 .. 
 
 210 
 
 39 
 
 139 
 
 30 
 
 71 
 
 32 
 
 68 
 
 29 
 
 71 
 
 85 
 
 32 
 
 85 
 
 39 
 
 85 
 
 1906 .. 
 
 175 
 
 32 
 
 113 
 
 24 
 
 64 
 
 28 
 
 49 
 
 21 
 
 62 
 
 73 
 
 36 
 
 94 
 
 26 
 
 56 
 
 1907 .. 
 
 178 
 
 32 
 
 108 
 
 23 
 
 60 
 
 26 
 
 48 
 
 20 
 
 70 
 
 81 
 
 42 
 
 108 
 
 28 
 
 59 
 
 1908 .. 
 
 164 
 
 29 
 
 118 
 
 25 
 
 66 
 
 29 
 
 52 
 
 22 
 
 46 
 
 53 
 
 24 
 
 61 
 
 22 
 
 46 
 
 1909 .. 
 
 167 
 
 30 
 
 117 
 
 24 
 
 64 
 
 27 
 
 53 
 
 22 
 
 50 
 
 57 
 
 23 
 
 57 
 
 27 
 
 56 
 
 1910 .. 
 
 162 
 
 28 
 
 111 
 
 23 
 
 57 
 
 24 
 
 54 
 
 22 
 
 51 
 
 57 
 
 29 
 
 71 
 
 22 
 
 45 
 
 1911 .. 
 
 223 
 
 39 
 
 141 
 
 29 
 
 81 
 
 34 
 
 60 
 
 24 
 
 82 
 
 90 
 
 45 
 
 109 
 
 37 
 
 75 
 
 1912 .. 
 
 204 
 
 35 
 
 129 
 
 26 
 
 72 
 
 30 
 
 57 
 
 23 
 
 75 
 
 81 
 
 44 
 
 105 
 
 31 
 
 62 
 
 1913 .. 
 
 203 
 
 34 
 
 125 
 
 25 
 
 61 
 
 25 
 
 64 
 
 25 
 
 78 
 
 84 
 
 39 
 
 92 
 
 39 
 
 77 
 
 1914 .. 
 
 199 
 
 33 
 
 109 
 
 22 
 
 63 
 
 26 
 
 46 
 
 18 
 
 90 
 
 95 
 
 50 
 
 116 
 
 40 
 
 78 
 
 1915 .. 
 
 193 
 
 32 
 
 125 
 
 25 
 
 66 
 
 26 
 
 59 
 
 23 
 
 68 
 
 71 
 
 46 
 
 106 
 
 22 
 
 42 
 
 1916 .. 
 
 200 
 
 33 
 
 107 
 
 21 
 
 62 
 
 25 
 
 45 
 
 17 
 
 93 
 
 96 
 
 53 
 
 120 
 
 40 
 
 76 
 
 1917 .. 
 
 194 
 
 32 
 
 128 
 
 25 
 
 69 
 
 27 
 
 59 
 
 23 
 
 66 
 
 67 
 
 36 
 
 80 
 
 30 
 
 56 
 
 1918 .. 
 
 220 
 
 36 
 
 126 
 
 24 
 
 71 
 
 28 
 
 55 
 
 21 
 
 94 
 
 95 
 
 57 
 
 126 
 
 37 
 
 69 
 
 1919 .. 
 
 216 
 
 30 
 
 132 
 
 21 
 
 68 
 
 22 
 
 64 
 
 21 
 
 84 
 
 81 
 
 48 
 
 100 
 
 36 
 
 64 
 
 1920 .. 
 
 171 
 
 23 
 
 99 
 
 16 
 
 53 
 
 17 
 
 46 
 
 15 
 
 72 
 
 66 
 
 40 
 
 75 
 
 32 
 
 58 
 
FEBRILE DISEASES 
 
 389 
 
 consequence for all forms of tuberculosis are uniformly much higher than for 
 whites. For pulmonary tuberculosis during these 45 years, there is signifi¬ 
 cantly close correspondence in the general course of the rates for whites, 
 negroes, and total population. The rate of decline for whites is strikingly 
 more acute than for negroes between 1875 and 1900. After the break in the 
 descent of the courses of the rates for both races due to the sharp rise between 
 1900 and 1905, as shown by the rates as averaged for 5-year periods (table 
 
 Table 81 .—Average rate of death, per 100,000 living inhabitants, by 5-year periods, 
 from all forms of tuberculosis, pulmonary tuberculosis, and other forms of tubercu¬ 
 losis, according to color and sex, from 1876 to 1920, inclusive. 
 
 PULMONARY TUBERCULOSIS. 
 
 
 Periods. 
 
 Total. 
 
 White. 
 
 Colored. 
 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 
 
 1876 to 
 
 1880. 
 
 355 
 
 299 
 
 296 
 
 303 
 
 663 
 
 658 
 
 668 
 
 1881 to 
 
 1885. 
 
 340 
 
 279 
 
 275 
 
 283 
 
 667 
 
 716 
 
 629 
 
 1886 to 
 
 1890. 
 
 286 
 
 239 
 
 248 
 
 230 
 
 552 
 
 574 
 
 534 
 
 1891 to 
 
 1895. 
 
 243 
 
 199 
 
 211 
 
 189 
 
 485 
 
 548 
 
 435 
 
 1896 to 
 
 1900. 
 
 215 
 
 174 
 
 198 
 
 153 
 
 440 
 
 504 
 
 388 
 
 1901 to 
 
 1905. 
 
 235 
 
 189 
 
 216 
 
 163 
 
 488 
 
 579 
 
 414 
 
 1906 to 
 
 1910. 
 
 228 
 
 179 
 
 209 
 
 150 
 
 498 
 
 582 
 
 429 
 
 1911 to 
 
 1915. 
 
 195 
 
 148 
 
 179 
 
 117 
 
 444 
 
 530 
 
 373 
 
 1916 to 
 
 1920. 
 
 r 172 
 
 \ 193* 
 
 129 
 
 150* 
 
 jl56 
 
 102 
 
 406 
 
 470 
 
 353 
 
 OTHER FORMS TUBERCULOSIS. 
 
 1901 to 1905. 
 
 33 
 
 26 
 
 28 
 
 25 
 
 71 
 
 83 
 
 61 
 
 1906 to 1910. 
 
 30 
 
 24 
 
 27 
 
 21 
 
 64 
 
 78 
 
 52 
 
 1911 to 1915. 
 
 35 
 
 25 
 
 28 
 
 23 
 
 84 
 
 106 
 
 67 
 
 1916 to 1920. 
 
 31 
 
 21 
 
 24 
 
 19 
 
 81 
 
 100 
 
 65 
 
 ALL FORMS TUBERCULOSIS. 
 
 1901 to 1905. 
 
 268 
 
 215 
 
 244 
 
 187 
 
 559 
 
 662 
 
 475 
 
 1906 to 1910. 
 
 259 
 
 203 
 
 236 
 
 171 
 
 562 
 
 660 
 
 481 
 
 1911 to 1915. 
 
 229 
 
 173 
 
 207 
 
 140 
 
 529 
 
 615 
 
 440 
 
 1916 to 1920. 
 
 J 203 
 
 1 224* 
 
 150 
 
 172* 
 
 J- 179 
 
 122 
 
 487 
 
 570 
 
 418 
 
 * Inclusive of 5-year average of deaths from pulmonary tuberculosis in sanatoria. 
 
 81), the curve for whites resumes its downward course immediately after 
 1905, and that for negroes not until 5 years later. The curves of the rates 
 as averaged for 10-year periods from 1880 to 1920 show for the negro a sharp 
 rise between 1900 and 1910, succeeded by a corresponding fall during the 
 final 10-year period, while for whites the curve continues to descend between 
 1900 and 1910, but at an angle much less acute than before, and during the 
 final 10-year period its angle of fall is again acute. The degree of decline in 
 the rates based upon the official figures after 1910 is sharper for whites than 
 for negroes, but this difference is apparent rather than real, for it disappears 
 
390 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 when in the comparison the true rate for whites (table 85) is substituted for 
 the official rate. The curve of the rate for the total population follows more 
 closely that for the whites because of the predominantly greater numbers of 
 the latter. 
 
 Coming now to other forms of tuberculosis, during the 20 years for which 
 comparative figures exist the rates for whites have fallen and those for 
 negroes risen, and the latter out of all proportion to the former. 
 
 The curves for whites and negroes for all forms of tuberculosis since 1900 
 show a much sharper fall for the former than for the latter race, but this dif¬ 
 ference in the angle of descent is much less marked when the curve for the true 
 rates for whites is substituted for the curve of the misleading official rates. 
 
 The influence of sex upon deaths from tuberculosis can be determined for 
 both whites and negroes for pulmonary tuberculosis since 1875 and for other 
 and all forms since 1900 (tables 80 and 81, graph 24). While the annual 
 rates for pulmonary tuberculosis for total population and for whites and for 
 negroes have fallen in 45 years from 341, 298, and 580 to 128, 99, and 294, 
 respectively, the rates for the sexes have fallen as follows: white males from 
 292 to 109; colored males from 627 to 265; white females from 303 to 89; 
 and negro females from 546 to 233. Or, measured by the decline in rates 
 averaged for 5-year periods the total rate has declined by 52 per cent (true 
 rate by 46 per cent) ; the total whites by 57 per cent (true rate by 50 per 
 cent) ; male white by 47 per cent; female white by 66 per cent; total negro 
 by 39 per cent; male negro by 29 per cent; and female negro by 47 per cent. 
 When the curves for the rates for pulmonary tuberculosis are plotted for race 
 and sex, it is apparent that, while each follows in general the same course of 
 the curves for the total population and for whites and negroes separately 
 during this period, the peaks characterizing the period 1901-1910 are less 
 marked and the descent occurring after the latter date is sharper in the 
 females than in the males of both races. In the case of each race the averaged 
 rates for females were at the beginning (1880) about the same as those for 
 the males, and in the case of whites there was scarcely any difference before 
 1890. After 1890 for whites and after 1880 for negroes, the rates for the sexes 
 deviate sharply, and by 1900 are widely separated. This in each instance is 
 due to the more rapid and steady fall in the female rates. Toward the end, 
 the angle of fall is somewhat more acute for white females and for negro 
 males than for white males and negro females. 
 
 For other forms of tuberculosis since 1900, the rates for males and females 
 of each race follow the same curve, but on the whole the course for whites is 
 downward and that for negroes is upward. In consequence of the latter fact, 
 and of the fact that the fall which occurred in the last 5-year period in the 
 rates for negroes of both sexes is less abrupt than that for whites, the curves 
 for all forms of tuberculosis fall less acutely for negroes of each sex than for 
 whites of each sex. 
 
 In table 80 and in graph 24 the course of tuberculosis, pulmonary, other 
 forms, and all forms, as previously described and illustrated for 5- and 10-year 
 averaged rates, may be followed for each particular year. It will be noted 
 that the upward and downward swings in the rates plotted by years do not 
 correspond exactly with those of the somewhat arbitrarily averaged rates, but 
 the correspondence is evidently sufficiently close to warrant the use made of 
 
FEBRILE DISEASES 
 
 391 
 
 the latter method and to support, on the whole, the conclusions following 
 from it. 
 
 A fact of considerable importance brought out by the graphic representation 
 of the total rates by years for pulmonary tuberculosis, throughout the period, 
 and for other forms and all forms since 1875, is that, while occasionally there 
 are abrupt rises and falls involving individual years, on the whole the annual 
 rates follow smooth courses over long swings either up or down. It will be 
 noted that there were slight declines in the mortality rates for pulmonary 
 tuberculosis after the influenza epidemics of 1814, 1849, and 1890, and a 
 marked decline during the two years following the severe one of 1918. The 
 lowest rate ever attained for the whole population previous to 1912 was in 
 
 1899, at the end of a long downward swing. After this date the rate gradually 
 ascended, and but for the favorable influence exerted by the registration of 
 sanatoria deaths out of the city and by the influenza epidemic of 1918, it is 
 unlikely that the rate of 1899 would have been notably bettered, since the 
 rates for both whites and negroes were apparently tending to stabilize after 
 1912 at the levels they had reached in 1899. It is of considerable interest 
 that a drop in the rate for other forms between 1880 and 1898 coincides very 
 closely with the fall that was occurring in that for pulmonary tuberculosis. 
 The decline in the death-rates for all forms of tuberculosis for male and 
 female of both races following the influenza epidemic of 1918 is striking. 
 There were only slight differences between the rates from pulmonary tubercu¬ 
 losis for males and females of both the white and black races between 1875 
 and 1890-1895. 
 
 According to Frick’s calculations, the mortality-rates for pulmonary tuber¬ 
 culosis in 1850 were 317 in whites and 468 in negroes. Of the total deaths of 
 this disease in both races, 43.5 per cent were in males and 56.5 per cent were 
 in females. There was no difference for the two sexes up to the fifteenth year 
 of age, but from the fifteenth to the forty-fifth year he found the percentage 
 of deaths was 38 for males and 62 for females. At that date the percentages 
 of males and females in the population were 47 and 53, respectively. It is 
 clear that in 1850 pulmonary tuberculosis was decidedly more fatal for 
 females than for males; 25 years later the rates for the two sexes were ap¬ 
 proximately the same, and since 1890-1895 the rate in females (in both 
 races) has gradually become much lower than in males. In the 67 years 
 between 1850 and 1917 the rate for whites fell by over 50 per cent (from 317 
 to 142), and the rate for negroes actually increased from 468 to 494. 
 
 Data are available for studying the influence of age upon the mortality from 
 pulmonary tuberculosis upon the whole population for the census years 1850, 
 
 1900, 1910, and 1920, upon whites and negroes of both sexes for 1910 and 
 1920, and for other forms of tuberculosis for 1910. Mortality-rates for 
 pulmonary tuberculosis in the various age-groups of the whole population in 
 these four census years are compared in table 82. Owing to differences of the 
 age-groupings of the deaths in Frick’s table for 1850, the rates for the 
 divisions after the sixtieth year of age can not be compared with those for the 
 other census years. As the figures for the total deaths as given in the general 
 and special tables vary somewhat, and the population figures of the Bureau 
 of the Census used in these calculations differ slightly from those used 
 routinely elsewhere, the rates for all ages in the table are not identical in three 
 
392 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 of the years from those of the general table (table 78) of mortality-rates for the 
 disease. They are 344, 239, and 221, for 1850, 1900, and 1910, instead of 354, 
 212, and 216, respectively. In both tables deaths occurring in extra-urban 
 sanatoria are excluded. 
 
 In 1850 the rate rose from 76 in the first decade of life to 145 in the second, 
 524 in the third, and 590 in the fourth. After receding to 510 in the fifth 
 decade, the rate rose to 716 in the sixth, and after the sixtieth year fell to 583. 
 In this year, therefore, the chances of dying of pulmonary tuberculosis were 
 conspicuously greatest in the sixth decade of life. It is likely that this dis¬ 
 tribution of deaths among the age-groups did not change materially until 
 after 1885. The course of the rates for the various age-groups was markedly 
 different in 1900, after a period of 15 years in which the mortality-rates had 
 been steadily declining. Though the rate for the first 5 years of life was 
 
 Table 82 .— Number of deaths and rate of death, per 100,000 living inhabitants, from 
 pulmonary tuberculosis, according to age, for 1850, 1900, 1910, and 1920. 
 
 D - death. R = rate. 
 
 Age-period. 
 
 1850 
 
 1900 
 
 1910 
 
 1920 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 
 Under 1 year. 
 
 5 
 
 82 
 
 32 
 
 295 
 
 6 
 
 59 
 
 2 
 
 13 
 
 Between 1 and 2 years... 
 
 2 to 4 years. 
 
 } 17 
 
 92 
 
 f 25 
 
 1 11 
 
 83 
 
 117 
 
 7 
 
 3 
 
 22 
 
 31 
 
 } 16 
 
 29 
 
 5 to 9 years. 
 
 12 
 
 60 
 
 32 
 
 63 
 
 9 
 
 18 
 
 7 
 
 11 
 
 0 to 9 years. 
 
 34 
 
 76 
 
 100 
 
 98 
 
 25 
 
 25 
 
 25 
 
 19 
 
 10 to 19 years. 
 
 53 
 
 145 
 
 118 
 
 120 
 
 104 
 
 101 
 
 76 
 
 61 
 
 20 to 29 years. 
 
 180 
 
 524 
 
 341 
 
 337 
 
 341 
 
 302 
 
 275 
 
 190 
 
 30 to 39 years. 
 
 145 
 
 590 
 
 284 
 
 356 
 
 305 
 
 344 
 
 203 
 
 166 
 
 40 to 49 years. 
 
 74 
 
 510 
 
 175 
 
 301 
 
 224 
 
 327 
 
 158 
 
 171 
 
 50 to 59 years. 
 
 58 
 
 716 
 
 104 
 
 287 
 
 136 
 
 301 
 
 102 
 
 163 
 
 60 years and over. 
 
 37 
 
 583 
 
 • • • • 
 
 • • • • 
 
 • • • • 
 
 • • • • 
 
 • • • • 
 
 • • • • 
 
 60 to 69 years. 
 
 • • • • 
 
 • • • • 
 
 64 
 
 309 
 
 75 
 
 302 
 
 72 
 
 200 
 
 70 to 79 years. 
 
 • • • • 
 
 • • • • 
 
 25 
 
 278 
 
 21 
 
 201 
 
 22 
 
 153 
 
 80 years and over. 
 
 • • • • 
 
 • • • • 
 
 4 
 
 185 
 
 3 
 
 112 
 
 3 
 
 86 
 
 Total . 
 
 581 
 
 344 
 
 1215 
 
 239 
 
 1234 
 
 221 
 
 936 
 
 128 
 
 notably higher than in 1850, there was little difference in the mortality 
 between the fifth and tenth years of age. Starting at the advanced level of 98 
 in the first decade of life, the rate rose but slightly in the second to 120, 
 sharply in the third, and attained 356, its highest point, in the fourth. From 
 this level, except for a slight reaction in the seventh decade, the rate fell grad¬ 
 ually through advancing years. In 1910, with a considerable decline in mor¬ 
 tality in all the age divisions below the tenth year, the rate for the first decade 
 was only 25. For the second, third, fourth, and seventh decades the rates 
 were not significantly lower than in 1900. It was in early and in advanced 
 life that the rates were lower than in 1900. In 1920, with rates for each age- 
 group considerably lower than in previous years, the highest rates occurred 
 in the third and seventh decades of life, the rates being considerably less in 
 the fourth, fifth, and sixth decades. As in other years after the completion 
 of the seventieth year, the chances of dying of pulmonary tuberculosis dimin¬ 
 ished sharply. 
 
FEBRILE DISEASES 
 
 393 
 
 It will be noted that the decades of highest mortality were the sixth in 
 1850, the fourth in 1900 and 1910, and the seventh in 1920. However, since 
 in 1920 the rate for the seventh decade was but slightly higher than in the 
 third, it would appear that with the decline in the total rate one of the chief 
 characteristics has been a relative decline in the rates before and after the 
 third decade of life. For the white population, in 1910, the mortality-rate 
 (table 83), comparatively low in the first 20 years of life, reached 213 in the 
 third decade. The mortality varied but slightly during the next 3 decades, but 
 between the sixtieth and the sixty-ninth years of life advanced to 287, its 
 highest level. After the seventieth year it fell gradually, but in extreme old 
 age the mortality-rate was still considerably higher than in childhood. In 1920, 
 the mortality-rate (table 84) in the white population followed a somewhat dif¬ 
 ferent course in the various age-groups. Instead of rising, it fell in the fourth 
 decade, and instead of running a level course during the fifth, sixth, and seventh 
 decades, the rate gradually rose from the fortieth to the seventieth year of life. 
 The decline during the remainder of life was much less and much more gradual 
 than in 1910. These differences, so far as the age-period between the twentieth 
 and fortieth years is concerned, were probably to some extent due to the larger 
 proportion of deaths occurring in extra-urban sanatoria in 1920 as compared 
 with 1910. 
 
 Among negroes, in 1910 (table 83), the rate was significantly higher than 
 in whites in every age-group, but the differences were conspicuously greater 
 at the extremes of life. The high level in the earlier years of life, attained in 
 contrast to the rate for whites in the third instead of in the fourth decade, 
 was maintained during the latter period. Between the fourth and the sixth 
 decades there was a gradual decline in the rates. After falling considerably 
 in the seventh, and remaining constant in the eighth decade, the rate ap¬ 
 proached the highest point in the age-period 80 and over. In 1920 (table 84), 
 with the very considerable fall in the total rate for all ages, as compared with 
 1910, there occurred a notable change in the rates for the different age-periods, 
 except the first and the seventh decades. As before, the highest level was 
 reached in the third decade of life, but during the fourth, fifth, and sixth 
 decades the rates descended steadily to a relatively very low level—from 444 
 to 191—and then rising sharply in the seventh decade, fell precipitously during 
 the remainder of life. It will be noted that in 1920, when in both races the 
 rates for all ages had undergone a marked recession as compared with 1910, 
 the mortality-rates ran quite different courses after the fortieth year of age. 
 
 The general course of the mortality-rates for white males in 1910 and 1920 
 are in many respects similar. In both years the rates rose between the third 
 and the seventh decades and fell during extreme old age. The main dif¬ 
 ferences are that in 1910 the high level attained in the fourth decade is main¬ 
 tained during the next two decades and in the seventh decade there is a sharp 
 rise in the rate, while in 1920 there is an unbroken ascent in the rates between 
 the third and the seventh decades. A significant difference is the lowered 
 rates in the second, third, and fourth decades of life in 1920 as compared 
 with 1910. In comparison of the course of the rates for white females in these 
 two years, there is to be noted that while high levels are reached in the third 
 decade in both years, in 1910 there is but little change during the next three 
 decades of life, while in 1920 the rates fall considerably during the latter 
 
394 
 
 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 Table 83. — Number of deaths and rate of death, per 100,000 living inhabitants, from 
 pulmonary tuberculosis, other forms of tuberculosis, and all forms of tuberculosis, 
 according to age, color, and sex, for 1910. 
 
 ALL FORMS OF TUBERCULOSIS. 
 
 D = death. R = rate. 
 
 Age-period. 
 
 Total. 
 
 White. 
 
 Colored. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 Under 1 year. 
 
 22 
 
 215 
 
 17 
 
 191 
 
 8 
 
 178 
 
 9 
 
 204 
 
 5 
 
 371 
 
 3 
 
 438 
 
 2 
 
 302 
 
 Betw. 1 and 2 years 
 
 14 
 
 146 
 
 10 
 
 118 
 
 6 
 
 137 
 
 4 
 
 98 
 
 4 
 
 355 
 
 1 
 
 180 
 
 3 
 
 526 
 
 2 to 4 years. 
 
 21 
 
 65 
 
 11 
 
 39 
 
 6 
 
 43 
 
 5 
 
 36 
 
 10 
 
 241 
 
 1 
 
 50 
 
 9 
 
 420 
 
 5 to 9 years. 
 
 21 
 
 42 
 
 9 
 
 21 
 
 5 
 
 23 
 
 4 
 
 19 
 
 12 
 
 187 
 
 4 
 
 131 
 
 8 
 
 238 
 
 0 to 9 years. 
 
 78 
 
 77 
 
 47 
 
 53 
 
 25 
 
 56 
 
 22 
 
 50 
 
 31 
 
 238 
 
 9 
 
 143 
 
 22 
 
 327 
 
 10 to 19 years. 
 
 136 
 
 132 
 
 72 
 
 81 
 
 26 
 
 61 
 
 46 
 
 100 
 
 64 
 
 465 
 
 29 
 
 496 
 
 35 
 
 442 
 
 20 to 29 years. 
 
 368 
 
 326 
 
 217 
 
 235 
 
 109 
 
 245 
 
 108 
 
 225 
 
 151 
 
 732 
 
 71 
 
 785 
 
 80 
 
 691 
 
 30 to 39 years. 
 
 327 
 
 368 
 
 211 
 
 289 
 
 123 
 
 346 
 
 88 
 
 235 
 
 116 
 
 734 
 
 69 
 
 902 
 
 47 
 
 576 
 
 40 to 49 years. 
 
 237 
 
 346 
 
 160 
 
 280 
 
 98 
 
 356 
 
 62 
 
 209 
 
 77 
 
 676 
 
 47 
 
 831 
 
 30 
 
 523 
 
 50 to 59 years. 
 
 144 
 
 319 
 
 107 
 
 274 
 
 67 
 
 355 
 
 40 
 
 198 
 
 37 
 
 610 
 
 23 
 
 777 
 
 14 
 
 451 
 
 60 to 69 years. 
 
 80 
 
 323 
 
 68 
 
 310 
 
 50 
 
 506 
 
 18 
 
 150 
 
 12 
 
 416 
 
 7 
 
 530 
 
 5 
 
 379 
 
 70 to 79 years. 
 
 23 
 
 220 
 
 19 
 
 201 
 
 10 
 
 254 
 
 9 
 
 163 
 
 4 
 
 402 
 
 1 
 
 248 
 
 3 
 
 506 
 
 80 years and over.. 
 
 3 
 
 112 
 
 1 
 
 42 
 
 1 
 
 117 
 
 • • • 
 
 • • • 
 
 2 
 
 676 
 
 1 
 
 1075 
 
 1 
 
 493 
 
 Total . 
 
 1396 
 
 250 
 
 902 
 
 191 
 
 509 
 
 222 
 
 393 
 
 161 
 
 494 
 
 581 
 
 257 
 
 653 
 
 237 
 
 518 
 
 PULMONARY TUBERCULOSIS. 
 
 Under 1 year. 
 
 6 
 
 59 
 
 4 
 
 45 
 
 1 
 
 22 
 
 3 
 
 68 
 
 2 
 
 148 
 
 1 
 
 146 
 
 1 
 
 151 
 
 Betw. 1 and 2 years 
 
 3 
 
 31 
 
 3 
 
 35 
 
 3 
 
 68 
 
 
 
 
 
 
 
 
 
 2 to 4 years. 
 
 7 
 
 22 
 
 2 
 
 7 
 
 1 
 
 7 
 
 1 
 
 7 
 
 5 
 
 120 
 
 • • • 
 
 • • • • 
 
 5 
 
 233 
 
 5 to 9 years. 
 
 9 
 
 18 
 
 1 
 
 2 
 
 1 
 
 5 
 
 • • • 
 
 • • • 
 
 8 
 
 125 
 
 3 
 
 98 
 
 5 
 
 149 
 
 0 to 9 years. 
 
 25 
 
 25 
 
 10 
 
 11 
 
 6 
 
 13 
 
 4 
 
 9 
 
 15 
 
 115 
 
 4 
 
 63 
 
 11 
 
 163 
 
 10 to 19 years. 
 
 104 
 
 101 
 
 54 
 
 61 
 
 18 
 
 42 
 
 36 
 
 78 
 
 50 
 
 363 
 
 20 
 
 342 
 
 30 
 
 379 
 
 20 to 29 years. 
 
 341 
 
 302 
 
 197 
 
 213 
 
 99 
 
 223 
 
 98 
 
 204 
 
 144 
 
 698 
 
 65 
 
 719 
 
 79 
 
 682 
 
 30 to 39 years. 
 
 305 
 
 344 
 
 197 
 
 270 
 
 118 
 
 332 
 
 79 
 
 211 
 
 108 
 
 683 
 
 64 
 
 837 
 
 44 
 
 539 
 
 40 to 49 years. 
 
 224 
 
 327 
 
 152 
 
 266 
 
 92 
 
 334 
 
 60 
 
 202 
 
 72 
 
 632 
 
 44 
 
 778 
 
 28 
 
 488 
 
 50 to 59 years. 
 
 136 
 
 301 
 
 100 
 
 256 
 
 62 
 
 328 
 
 38 
 
 188 
 
 36 
 
 594 
 
 22 
 
 743 
 
 14 
 
 451 
 
 60 to 69 years. 
 
 75 
 
 302 
 
 63 
 
 287 
 
 48 
 
 486 
 
 15 
 
 125 
 
 12 
 
 416 
 
 7 
 
 530 
 
 5 
 
 379 
 
 70 to 79 years. 
 
 21 
 
 201 
 
 17 
 
 180 
 
 8 
 
 203 
 
 9 
 
 163 
 
 4 
 
 402 
 
 1 
 
 248 
 
 3 
 
 506 
 
 80 years and over.. 
 
 3 
 
 112 
 
 1 
 
 42 
 
 1 
 
 117 
 
 • • • 
 
 • • • 
 
 2 
 
 676 
 
 1 
 
 1075 
 
 1 
 
 493 
 
 Total . 
 
 1234 
 
 221 
 
 791 
 
 167 
 
 452 
 
 198 
 
 339 
 
 139 
 
 443 
 
 521 
 
 228 
 
 579 
 
 215 
 
 470 
 
 OTHER FORMS OF TUBERCULOSIS. 
 
 Under 1 year. 
 
 16 
 
 156 
 
 13 
 
 146 
 
 7 
 
 156 
 
 6 
 
 136 
 
 3 
 
 223 
 
 2 
 
 292 
 
 1 
 
 151 
 
 Betw. 1 and 2 years 
 
 11 
 
 114 
 
 7 
 
 83 
 
 3 
 
 68 
 
 4 
 
 98 
 
 4 
 
 355 
 
 1 
 
 180 
 
 3 
 
 526 
 
 2 to 4 years. 
 
 14 
 
 44 
 
 9 
 
 32 
 
 5 
 
 36 
 
 4 
 
 29 
 
 5 
 
 120 
 
 1 
 
 50 
 
 4 
 
 187 
 
 5 to 9 years. 
 
 12 
 
 24 
 
 8 
 
 19 
 
 4 
 
 18 
 
 4 
 
 19 
 
 4 
 
 62 
 
 1 
 
 33 
 
 3 
 
 89 
 
 0 to 9 years. 
 
 53 
 
 52 
 
 37 
 
 42 
 
 19 
 
 43 
 
 18 
 
 41 
 
 16 
 
 123 
 
 5 
 
 79 
 
 11 
 
 163 
 
 10 to 19 years. 
 
 32 
 
 31 
 
 18 
 
 20 
 
 8 
 
 19 
 
 10 
 
 22 
 
 14 
 
 102 
 
 9 
 
 154 
 
 5 
 
 63 
 
 20 to 29 years. 
 
 27 
 
 24 
 
 20 
 
 22 
 
 10 
 
 22 
 
 10 
 
 21 
 
 7 
 
 34 
 
 6 
 
 66 
 
 1 
 
 9 
 
 30 to 39 years. 
 
 22 
 
 25 
 
 14 
 
 19 
 
 5 
 
 14 
 
 9 
 
 24 
 
 8 
 
 51 
 
 5 
 
 65 
 
 3 
 
 37 
 
 40 to 49 years. 
 
 13 
 
 19 
 
 8 
 
 14 
 
 6 
 
 22 
 
 2 
 
 7 
 
 5 
 
 44 
 
 3 
 
 53 
 
 2 
 
 35 
 
 50 to 59 years. 
 
 8 
 
 18 
 
 7 
 
 18 
 
 5 
 
 26 
 
 2 
 
 10 
 
 1 
 
 16 
 
 1 
 
 34 
 
 • • • 
 
 • • • 
 
 60 to 69 years. 
 
 5 
 
 20 
 
 5 
 
 23 
 
 2 
 
 20 
 
 3 
 
 25 
 
 
 
 
 
 
 
 70 to 79 years. 
 
 2 
 
 19 
 
 2 
 
 21 
 
 2 
 
 51 
 
 
 
 
 
 
 
 
 
 80 years and over.. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Total . 
 
 162 
 
 29 
 
 111 
 
 23 
 
 57 
 
 25 
 
 54 
 
 22 
 
 51 
 
 60 
 
 29 
 
 74 
 
 22 
 
 48 
 
FEBRILE DISEASES 
 
 395 
 
 Table 84. — Number of deaths and rate of death, per 100,000 living inhabitants, from 
 pulmonary tuberculosis, other forms of tuberculosis and all forms of tuberculosis, 
 according to age, color, and sex, for 1920. 
 
 ALL FORMS OF TUBERCULOSIS. 
 
 D = death. R = rate. 
 
 Age-periods. 
 
 Total. 
 
 White. 
 
 Colored. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 Under 1 year. 
 
 24 
 
 162 
 
 11 
 
 85 
 
 5 
 
 76 
 
 6 
 
 95 
 
 13 
 
 661 
 
 9 
 
 940 
 
 4 
 
 396 
 
 1 to 4 years. 
 
 46 
 
 84 
 
 27 
 
 56 
 
 13 
 
 54 
 
 14 
 
 58 
 
 19 
 
 297 
 
 6 
 
 193 
 
 13 
 
 395 
 
 5 to 9 years. 
 
 17 
 
 26 
 
 7 
 
 12 
 
 4 
 
 14 
 
 3 
 
 11 
 
 10 
 
 124 
 
 5 
 
 130 
 
 5 
 
 119 
 
 0 to 9 years. 
 
 87 
 
 65 
 
 45 
 
 38 
 
 22 
 
 37 
 
 23 
 
 40 
 
 42 
 
 255 
 
 20 
 
 252 
 
 22 
 
 258 
 
 10 to 19 years. 
 
 95 
 
 77 
 
 45 
 
 42 
 
 9 
 
 17 
 
 36 
 
 66 
 
 50 
 
 313 
 
 18 
 
 255 
 
 32 
 
 360 
 
 20 to 29 years. 
 
 306 
 
 211 
 
 176 
 
 148 
 
 76 
 
 129 
 
 100 
 
 166 
 
 130 
 
 503 
 
 50 
 
 410 
 
 80 
 
 586 
 
 30 to 39 years. 
 
 222 
 
 181 
 
 141 
 
 140 
 
 80 
 
 159 
 
 61 
 
 122 
 
 81 
 
 371 
 
 42 
 
 3S0 
 
 39 
 
 362 
 
 40 to 49 years. 
 
 174 
 
 188 
 
 122 
 
 159 
 
 76 
 
 199 
 
 46 
 
 119 
 
 52 
 
 334 
 
 35 
 
 422 
 
 17 
 
 233 
 
 50 to 59 years. 
 
 115 
 
 184 
 
 95 
 
 174 
 
 67 
 
 251 
 
 28 
 
 100 
 
 20 
 
 225 
 
 8 
 
 188 
 
 12 
 
 332 
 
 60 to 69 years. 
 
 80 
 
 222 
 
 65 
 
 200 
 
 44 
 
 287 
 
 21 
 
 122 
 
 15 
 
 433 
 
 7 
 
 409 
 
 8 
 
 457 
 
 70 to 79 years. 
 
 25 
 
 173 
 
 23 
 
 176 
 
 12 
 
 214 
 
 11 
 
 147 
 
 2 
 
 147 
 
 1 
 
 165 
 
 1 
 
 133 
 
 80 years and over... 
 
 3 
 
 86 
 
 3 
 
 96 
 
 2 
 
 178 
 
 1 
 
 50 
 
 
 
 
 
 
 
 Total . 
 
 1107 
 
 151 
 
 715 
 
 114 
 
 388 
 
 126 
 
 327 
 
 103 
 
 392 
 
 361 
 
 181 
 
 340 
 
 211 
 
 380 
 
 PULMONARY TUBERCULOSIS. 
 
 Under 1 year. 
 
 2 
 
 13 
 
 
 
 
 
 
 
 2 
 
 102 
 
 2 
 
 209 
 
 
 
 1 to 4 years. 
 
 16 
 
 29 
 
 4 
 
 8 
 
 2 
 
 8 
 
 2 
 
 8 
 
 12 
 
 187 
 
 4 
 
 128 
 
 8 
 
 243 
 
 5 to 9 years. 
 
 7 
 
 11 
 
 4 
 
 7 
 
 3 
 
 11 
 
 1 
 
 4 
 
 3 
 
 37 
 
 1 
 
 26 
 
 2 
 
 48 
 
 0 to 9 years. 
 
 25 
 
 19 
 
 8 
 
 7 
 
 5 
 
 8 
 
 3 
 
 5 
 
 17 
 
 103 
 
 7 
 
 88 
 
 10 
 
 117 
 
 10 to 19 years. 
 
 76 
 
 61 
 
 36 
 
 33 
 
 6 
 
 11 
 
 30 
 
 55 
 
 40 
 
 251 
 
 15 
 
 212 
 
 25 
 
 281 
 
 20 to 29 years. 
 
 275 
 
 190 
 
 161 
 
 135 
 
 68 
 
 116 
 
 93 
 
 154 
 
 114 
 
 441 
 
 44 
 
 361 
 
 70 
 
 513 
 
 30 to 39 years. 
 
 203 
 
 166 
 
 130 
 
 129 
 
 73 
 
 145 
 
 57 
 
 114 
 
 73 
 
 335 
 
 34 
 
 308 
 
 39 
 
 362 
 
 40 to 49 years. 
 
 158 
 
 171 
 
 111 
 
 145 
 
 68 
 
 178 
 
 43 
 
 112 
 
 47 
 
 302 
 
 31 
 
 374 
 
 16 
 
 219 
 
 50 to 59 years. 
 
 102 
 
 163 
 
 87 
 
 159 
 
 61 
 
 229 
 
 26 
 
 93 
 
 15 
 
 191 
 
 5 
 
 118 
 
 10 
 
 277 
 
 60 to 69 years. 
 
 72 
 
 200 
 
 59 
 
 181 
 
 40 
 
 261 
 
 19 
 
 110 
 
 13 
 
 375 
 
 5 
 
 292 
 
 8 
 
 457 
 
 70 to 79 years. 
 
 22 
 
 153 
 
 21 
 
 161 
 
 12 
 
 214 
 
 9 
 
 121 
 
 1 
 
 74 
 
 • • • 
 
 • • • 
 
 1 
 
 133 
 
 80 years and over... 
 
 3 
 
 86 
 
 3 
 
 96 
 
 2 
 
 178 
 
 1 
 
 50 
 
 
 
 
 
 
 
 Total . 
 
 936 
 
 128 
 
 616 
 
 99 
 
 335 
 
 109 
 
 281 
 
 89 
 
 320 
 
 295 
 
 141 
 
 265 
 
 179 
 
 323 
 
 OTHER FORMS OF TUBERCULOSIS. 
 
 Under 1 year... 
 
 22 
 
 148 
 
 11 
 
 85 
 
 5 
 
 76 
 
 6 
 
 95 
 
 11 
 
 559 
 
 7 
 
 731 
 
 4 
 
 396 
 
 1 to 4 years. 
 
 30 
 
 55 
 
 23 
 
 48 
 
 11 
 
 46 
 
 12 
 
 50 
 
 7 
 
 109 
 
 2 
 
 64 
 
 5 
 
 152 
 
 5 to 9 years. 
 
 10 
 
 16 
 
 3 
 
 5 
 
 1 
 
 4 
 
 2 
 
 7 
 
 7 
 
 87 
 
 4 
 
 104 
 
 3 
 
 71 
 
 0 to 9 years. 
 
 62 
 
 46 
 
 37 
 
 32 
 
 17 
 
 29 
 
 20 
 
 34 
 
 25 
 
 152 
 
 13 
 
 164 
 
 12 
 
 141 
 
 10 to 19 years. 
 
 19 
 
 15 
 
 9 
 
 8 
 
 3 
 
 6 
 
 6 
 
 11 
 
 10 
 
 63 
 
 3 
 
 42 
 
 7 
 
 79 
 
 20 to 29 years. 
 
 31 
 
 21 
 
 15 
 
 13 
 
 8 
 
 14 
 
 7 
 
 12 
 
 16 
 
 62 
 
 6 
 
 49 
 
 10 
 
 73 
 
 30 to 39 years. 
 
 19 
 
 16 
 
 11 
 
 11 
 
 7 
 
 14 
 
 4 
 
 8 
 
 8 
 
 37 
 
 8 
 
 72 
 
 • • • 
 
 • • • 
 
 40 to 49 years. 
 
 16 
 
 17 
 
 11 
 
 14 
 
 8 
 
 21 
 
 3 
 
 8 
 
 5 
 
 32 
 
 4 
 
 48 
 
 1 
 
 14 
 
 50 to 59 years. 
 
 13 
 
 21 
 
 8 
 
 15 
 
 6 
 
 22 
 
 2 
 
 7 
 
 5 
 
 64 
 
 3 
 
 71 
 
 2 
 
 55 
 
 60 to 69 years. 
 
 8 
 
 22 
 
 6 
 
 18 
 
 4 
 
 26 
 
 2 
 
 12 
 
 2 
 
 58 
 
 2 
 
 117 
 
 • • • 
 
 • • • 
 
 70 to 79 years. 
 
 3 
 
 21 
 
 2 
 
 15 
 
 • • • 
 
 • • • 
 
 2 
 
 27 
 
 1 
 
 74 
 
 1 
 
 165 
 
 • • • 
 
 • • • 
 
 80 years and over... 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Total . 
 
 171 
 
 23 
 
 99 
 
 16 
 
 53 
 
 17 
 
 46 
 
 15 
 
 72 
 
 66 
 
 40 
 
 75 
 
 32 
 
 58 
 
 26 
 
396 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 period. Though the rates were lower before the thirtieth and after the sixtieth 
 years of life in 1920 than in 1910, the really significant differences lay between 
 the thirtieth and sixtieth years. In negro males the rates in 1910 ascended by 
 rather uniform grades through the first four decades of life, and after falling 
 somewhat during the fifth and sixth, descended markedly during the seventh 
 and eighth decades, to rise sharply in extreme old age to the highest level 
 attained. In 1920, although the rates were considerably higher in the first 
 10 years of life than in 1910, thereafter they were much lower. Reaching 
 a much lower level in the third decade, the rates fell somewhat in the fourth, 
 rose in the fifth to a point slightly higher than in the third, and descended 
 sharply in the sixth decade. After a considerable reaction in the seventh 
 decade, which, however, fell far short of the previous high levels, the rate 
 declined sharply in extreme old age. 
 
 In both 1910 and 1920 the highest rates for the negroes were reached in 
 the third decade of life. In the former year there was a gradual recession of 
 the rates during the fourth, fifth, sixth, and seventh decades, followed by a 
 rise after the seventieth year. In the latter year there was a sharp decline in 
 the rate during the fourth and fifth, with a corresponding rise during the 
 sixth and seventh decades, and an abrupt fall after the seventieth year. It will 
 be noted that in 1920 the rate for all ages was higher in female than in male 
 negroes, and that this increase was due to higher rates in every decade of life 
 except the fifth. The peculiar shape of the curve for the total rate at all ages 
 for negroes in 1920 was determined largely by age distribution of deaths 
 among the females. Speaking generally, it may be said that the evidence at 
 hand indicates that in a period of decline in the total rates for all ages in the 
 whole population, the fall in the rates has affected all age-groups and in much 
 the same proportion. It further appears that the characteristics obtaining in 
 1910 for the rates in the different age-groups in whites and in negroes and in 
 males and in females of both races were on the whole preserved in 1920. The 
 inference seems justified, therefore, that the causes, whatever they may be, 
 to which the decline in the rates have been due, have acted with a certain 
 degree of uniformity. 
 
 Mortality rates for other forms of tuberculosis specific for color, sex, and 
 age in 1910 are given in table 83. In whites the high rates of the early years 
 fell sharply after the tenth year of life, while in negroes they persisted through 
 the second decade. For the whole population and among whites the rates 
 varied within narrow limits throughout life after the tenth year, but the 
 rates for negroes were much less stable. The negroes’ career with these forms 
 of tuberculosis is apparently closed with the sixtieth year of age, while the 
 white is pursued through old age. The rates for male and female whites 
 followed much the same course through the earlier decades of life. The male 
 rate showed a sharp fall in the fourth decade, followed by a rise lasting prac¬ 
 tically throughout the remainder of life. The female rate, on the other hand, 
 rose during the fourth decade, fell sharply in the fifth, and ascended during 
 the sixth and seventh. Among negroes the rate for males rose to its highest 
 point in the second decade and fell in the third to a level which was not 
 widely departed from until after the fiftieth year. In the female the rate, 
 reaching in the first decade a level double that for males, conspicuously fell 
 in the second and third decades and rebounded to a relatively high point in 
 
FEBRILE DISEASES 
 
 307 
 
 the fourth and fifth decades. In general, then, the rates for the two sexes in 
 the negro pursued opposite courses. The peak of mortality occurred in the 
 male in the second and in the female in the first decade of life. The negro 
 male, less severely affected than the female in the first decade, repaid this 
 debt during the remainder of life. The female paid her tribute in early life 
 and in middle age. In 1920, for the whole population (table 84), the rates 
 were lower in each age-group below the sixtieth year than in 1910. For the 
 whites, the rates were lower in each age-group except among females in the 
 sixth and eighth decades. Among negroes, the rates were uniformly higher 
 in all categories in the first year of life; for males for every age-group except 
 1 to 4 years and the second, third, and fifth decades; and for females in the 
 age-groups under 1 year, 5 to 9, and in the second, third, and sixth decades. 
 
 When the decline in the mortality of all forms of tuberculosis from 1900 to 
 1920 is measured by the percentage of decrease by 10-year periods for each age- 
 group, as illustrated by graph 25, it is evident that the greatest decline, over 55 
 
 A6E GROUPS 
 
 Graph 25. Percentages of decrease, occurring between 1900 and 1920, in 
 rates of mortality, specific for the decades of life, from all forms of tubercu¬ 
 losis in the whole population. 
 
 per cent, has occurred in the early ages. During the second and third decades 
 of life, the percentages of decrease were approximately 29 and 25, respectively. 
 An increase in the rate of decline (32 per cent) is noticeable during the fourth 
 decade, after which time 25 per cent decrease obtained until during the seventh 
 decade, when it dropped to 20. After the seventieth year, the rate of decline 
 increased until in the later years of life the relative chance of dying from 
 this disease was no greater than during early middle age. A straight line fitted 
 to this curve indicates that the decrease in the death-rate was not only greatest 
 in the earlier years of life, but gradually diminished with advancing years. 
 
 The records of the Bureau of Statistics give the reported cases of pulmonary 
 tuberculosis in the whole population, without distinction for race, sex, and age, 
 from 1900 to 1920, inclusive. The morbidity and mortality rates for this 
 period are compared in table 85 and graph 26. From this table it is evident 
 that the ordinance of 1894, requesting physicians to report cases, met with 
 but little response, and that the effects of the state law of 1906 making 
 pulmonary tuberculosis a reportable disease were slight before 1910. Before 
 the latter date the bulk of the registered cases were not reported directly, but 
 
398 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 Table 85 .—Number of cases, reported and estimated and respective rates, per 100,000 
 living inhabitants, and number of deaths and rate of death, per 100,000 living in¬ 
 habitants, in the city and extra-urban sanatoria, from pulmonary tuberculosis, from 
 1900 to 1920, inclusive. 
 
 C = cases. R = rate. D = death. R = rate. 
 
 Year. 
 
 Morbidity. 
 
 Mortality. 
 
 C 
 
 R 
 
 Esti¬ 
 
 mated 
 
 rate. 
 
 City. 
 
 Sanatoria. 
 
 Total. 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 1900 . 
 
 274 
 
 54 
 
 318 
 
 1077 
 
 212 
 
 
 • • • • 
 
 • • • • 
 
 
 1901 . 
 
 384 
 
 75 
 
 338 
 
 1158 
 
 225 
 
 
 
 
 
 1902 . 
 
 356 
 
 68 
 
 342 
 
 1188 
 
 228 
 
 
 
 
 
 1903 . 
 
 551 
 
 104 
 
 346 
 
 1216 
 
 231 
 
 
 
 
 
 1904 . 
 
 476 
 
 89 
 
 385 
 
 1375 
 
 257 
 
 
 
 
 
 1905 . 
 
 715 
 
 132 
 
 349 
 
 1261 
 
 233 
 
 
 
 
 
 1906 . 
 
 733 
 
 134 
 
 361 
 
 1317 
 
 241 
 
 
 
 
 
 1907 . 
 
 712 
 
 129 
 
 357 
 
 1317 
 
 238 
 
 
 
 
 
 1908 . 
 
 745 
 
 133 
 
 334 
 
 1250 
 
 223 
 
 
 
 
 
 1909 . 
 
 919 
 
 162 
 
 337 
 
 1273 
 
 225 
 
 
 
 
 
 1910 . 
 
 3292 
 
 575 
 
 324 
 
 1234 
 
 216 
 
 
 
 
 
 1911 . 
 
 1712 
 
 296 
 
 301 
 
 1165 
 
 201 
 
 
 
 
 
 1912 . 
 
 2248 
 
 385 
 
 306 
 
 1189 
 
 204 
 
 
 
 • • • • 
 
 
 1913 . 
 
 1541 
 
 261 
 
 
 1138 
 
 193 
 
 72 
 
 14 
 
 1210 
 
 207 
 
 1914 . 
 
 1410 
 
 237 
 
 
 1145 
 
 192 
 
 83 
 
 17 
 
 1228 
 
 209 
 
 1915 . 
 
 1694 
 
 282 
 
 
 1098 
 
 183 
 
 66 
 
 13 
 
 1164 
 
 196 
 
 1916 . 
 
 1830 
 
 302 
 
 
 1121 
 
 185 
 
 111 
 
 22 
 
 1232 
 
 207 
 
 1917 . 
 
 2011 
 
 328 
 
 
 1213 
 
 198 
 
 125 
 
 24 
 
 1338 
 
 222 
 
 1918 . 
 
 2036 
 
 330 
 
 
 1273 
 
 206 
 
 138 
 
 27 
 
 1411 
 
 233 
 
 1919 .. 
 
 1867 
 
 259 
 
 
 1029 
 
 143 
 
 131 
 
 21 
 
 1160 
 
 164 
 
 1920 . 
 
 1407 
 
 192 
 
 
 936 
 
 128 
 
 85 
 
 14 
 
 1021 
 
 142 
 
 Graph 26 (from table 85). Comparison of official and estimated crude 
 mortality and morbidity rates from pulmonary tuberculosis in the whole 
 population from 1900 to 1920, inclusive. 
 
FEBRILE DISEASES 
 
 399 
 
 were recorded through the bacteriological laboratory as the result of sputum 
 examinations. It was not until 1909 that the rate of recorded morbidity 
 approached the mortality-rates and not until 1910 the the latter was exceeded 
 by the former. The sudden great increase in the number of cases registered 
 in 1910 was associated with the activity of the newly established division 
 of tuberculosis, as the result of which a considerable number of cases pre¬ 
 viously known to physicians, dispensaries, and charitable agencies were at this 
 time reported. Therefore, the morbidity-rate of this exceptional year was 
 never again attained. Owing to careful scrutiny of the death certificates, 
 since 1910 but few recognized cases of pulmonary tuberculosis have died with¬ 
 out having been previously reported as clinical cases. In the 4-year period 
 1911-1914, there was a considerable drop in the morbidity-rate. During the 
 four years 1915-1918 the rates rose continuously, but in 1919 and 1920 there 
 was an abrupt fall. 
 
 The mortality-rates, though subject to annual fluctuations, did not, except 
 for the rise culminating in 1904, vary very significantly between 1900 and 
 1912, and if the rates corrected for deaths in extra-urban sanitaria after 1912 
 be taken into account, they were at about the same level in 1914 as in 1900. 
 After a slight recession in 1915, the mortality-rates, like the morbidity-rates, 
 rose steadily until 1918, and dropped as abruptly in the next 2 years. In 
 explanation of these facts, it is probably correct to assume that, on the whole, 
 between 1910 and 1914, inclusive, most of the existing cases of active pul¬ 
 monary tuberculosis belonging to the classes likely to be reported through 
 one agency or another had been recorded. If this be true, it follows that the 
 rise in the morbidity-rates between 1914 and 1918 and in the mortality-rates 
 between 1915 and 1918, and the subsequent abrupt decline in both during 
 1919 and 1920, represent a distinct correlation between incidence and fatality 
 of this disease since 1914. On an average in each year between 1914 and 1920, 
 the morbidity exceeded the mortality-rate by about one-half. 
 
 In the light of these observations, several important inferences may be 
 drawn. In the first place, had case reporting obtained before 1914 on the 
 same plane as after this date, the course of the curves of morbidity and of 
 mortality would probably have shown the same correspondence during the 
 former as they did during the latter period, i. e., the fallaciously low rates 
 before 1910 and the inordinately high rates between 1910 and 1912 would 
 be replaced by morbidity-rates approximately one-half higher than the mor¬ 
 tality-rates between 1900 and 1912. In this case the correct rates for the 
 period before 1910 would not be far from those indicated by the estimated 
 figures in table 85 and by the dotted line on the graph. 
 
 A second inference of importance is that within the limits of the experience 
 of 1914-1920 the conditions determining the rises and falls in the rate of 
 incidence effected simultaneously corresponding changes in the rate of death 
 from pulmonary tuberculosis. In other words, the conditions which in a 
 given time determine whether larger or smaller numbers of those exposed 
 shall develop into clinical cases are also directly concerned in settling the 
 rates in respect of time at which those so affected shall die of this disease. 
 Whether the decline in both morbidity and mortality-rates in 1919 and 1920 
 was due solely to changes wrought by the influenza epidemic of 1918, or to 
 these and to other causes as well, it is significant that both the incidence and 
 
400 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 the fatality of this disease, essentially chronic in the large proportion of 
 cases, at least, were affected in almost equal degree. While the low death- 
 rate of 1920 may have been in large measure directly dependent upon the 
 lowered morbidity of 1919 and 1920, after 3 years of increasing high inci¬ 
 dence there were ample clinical cases in reserve for a death-rate in 1919 
 at least as high as that of 1918 had not conditions which determine rapid 
 decline to a fatal issue ceased to act with their former force. As the margin 
 between the number of cases of pulmonary tuberculosis arriving annually in 
 the clinical state leading to reporting and the number of annual deaths is 
 relatively small—not far from one-half—and as some of the cases reported 
 recover, it follows that sudden rises in the death-rate must be first and 
 largely at the expense of the reservoir of established cases. 
 
 The question of the degree with which the recorded morbidity since 1914 
 has reflected actual occurrence will be considered later. 
 
 For determining the distribution of reported cases of pulmonary tubercu¬ 
 losis by race and sex over a term of years, the only available data are the cases 
 
 Table 86. —Number of reported cases and rate of morbidity, per 100,000 living inhabi¬ 
 tants, of tuberculosis, according to color and sex, from 1916 to 1920, inclusive. 
 
 C = cases. It = rate. 
 
 
 Total. 
 
 
 
 White. 
 
 
 
 
 
 Colored. 
 
 
 
 Year. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 
 C 
 
 R 
 
 C 
 
 R 
 
 C 
 
 R 
 
 C 
 
 R 
 
 C 
 
 R 
 
 i 
 
 C 
 
 R 
 
 C 
 
 R 
 
 1916 .. 
 
 1747 
 
 288 
 
 1413 
 
 277 
 
 617 
 
 245 
 
 796 
 
 308 
 
 334 
 
 345 
 
 168 
 
 380 
 
 166 
 
 316 
 
 1917 .. 
 
 1618 
 
 264 
 
 1261 
 
 245 
 
 731 
 
 287 
 
 530 
 
 204 
 
 357 
 
 365 
 
 176 
 
 393 
 
 181 
 
 341 
 
 1918 .. 
 
 1520 
 
 246 
 
 1191 
 
 230 
 
 725 
 
 282 
 
 466 
 
 178 
 
 329 
 
 332 
 
 177 
 
 391 
 
 152 
 
 283 
 
 1919 .. 
 
 1345 
 
 187 
 
 1003 
 
 163 
 
 543 
 
 177 
 
 460 
 
 149 
 
 342 
 
 328 
 
 156 
 
 326 
 
 186 
 
 330 
 
 1920 .. 
 
 1242 
 
 169 
 
 928 
 
 148 
 
 554 
 
 180 
 
 374 
 
 118 
 
 314 
 
 289 
 
 149 
 
 280 
 
 165 
 
 297 
 
 added to the visiting lists of the nurses of the tuberculosis division in the 
 5-year period 1916-1920. This material, which is presented in table 86, reflects 
 but a rough approximation to actual occurrence. The figures for each year 
 represent the number of cases out of the total number reported, either in the 
 same or in some previous year, for which consent for nursing supervision was 
 gTanted by the patient or by the attending physician. Thei discrepancy 
 between these two categories is perhaps not only variable, but often consider¬ 
 able. Taking the material at its face value, however, it is notable that, on the 
 whole, the proportional distribution of cases, as indicated by morbidity-rates, 
 among whites and negroes and among males and females of the two races, is 
 much the same as that found for deaths. Striking exceptions are, however, 
 the higher rates for females than for males among whites in 1916 and among 
 negroes in 1919 and 1920. The more accurate data concerning morbidity by 
 color, sex, and age, which exist in 1921 (rates calculated on the figures of the 
 Bureau of the Census of the population in 1920) are given in table 87. The 
 proportional distribution of reported cases in this year according to these 
 three categories corresponds in some degree with that found to obtain for 
 
FEBRILE DISEASES 
 
 401 
 
 deaths in 1920. For the whole population, as well as for whites and for 
 negroes, there is the same sharp ascent of the rates from early youth to a peak 
 reached in the third decade of life. 
 
 From this period onwards the morbidity-rates decline much more sharply 
 than do the mortality-rates. The shape of the curves is very similar for the 
 morbidity-rates for the three categories. As between males and females, 
 among whites, the rates for the latter are higher under the twentieth year, 
 lower between the twentieth and thirtieth years, and after the latter age show 
 a sharp decline which continues, but for a slight reaction in the seventh decade, 
 throughout the remainder of life. In males, on the contrary, the high level 
 attained in the third decade is maintained during the fourth and fifth decades. 
 After a sharp decline in the sixth decade, the rate remains very much on the 
 
 Table 87.— Morbidity, per 100,000 living inhabitants, from pulmonary tuberculosis, ac¬ 
 cording to age, color, and sex, for 1921. 
 
 O = cases. R = rate. 
 
 
 Total. 
 
 White. 
 
 Colored. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 O 
 
 R 
 
 C 
 
 R 
 
 O 
 
 R 
 
 C 
 
 R 
 
 C 
 
 R 
 
 C 
 
 R 
 
 C 
 
 R 
 
 Under 1 year. 
 
 9 
 
 61 
 
 5 
 
 39 
 
 4 
 
 61 
 
 1 
 
 16 
 
 4 
 
 203 
 
 2 
 
 209 
 
 2 
 
 198 
 
 1 to 4 years. 
 
 40 
 
 73 
 
 20 
 
 42 
 
 9 
 
 37 
 
 11 
 
 46 
 
 20 
 
 312 
 
 10 
 
 321 
 
 10 
 
 304 
 
 5 to 9 years. 
 
 50 
 
 78 
 
 38 
 
 67 
 
 17 
 
 59 
 
 21 
 
 75 
 
 12 
 
 149 
 
 5 
 
 130 
 
 7 
 
 166 
 
 Under 10 years.... 
 
 99 
 
 74 
 
 63 
 
 54 
 
 30 
 
 51 
 
 33 
 
 57 
 
 36 
 
 219 
 
 17 
 
 214 
 
 19 
 
 223 
 
 10 to 19 years. 
 
 173 
 
 140 
 
 101 
 
 94 
 
 44 
 
 83 
 
 57 
 
 104 
 
 72 
 
 451 
 
 21 
 
 297 
 
 51 
 
 574 
 
 20 to 29 years. 
 
 460 
 
 317 
 
 330 
 
 277 
 
 185 
 
 315 
 
 145 
 
 241 
 
 130 
 
 503 
 
 71 
 
 583 
 
 59 
 
 432 
 
 30 to 39 years. 
 
 299 
 
 244 
 
 231 
 
 230 
 
 143 
 
 284 
 
 88 
 
 176 
 
 68 
 
 312 
 
 41 
 
 371 
 
 27 
 
 251 
 
 40 to 49 years. 
 
 220 
 
 238 
 
 161 
 
 210 
 
 117 
 
 306 
 
 44 
 
 114 
 
 59 
 
 379 
 
 41 
 
 495 
 
 18 
 
 247 
 
 50 to 59 years. 
 
 85 
 
 136 
 
 69 
 
 126 
 
 43 
 
 161 
 
 26 
 
 93 
 
 16 
 
 204 
 
 11 
 
 259 
 
 5 
 
 138 
 
 60 to 69 years. 
 
 44 
 
 122 
 
 41 
 
 126 
 
 22 
 
 144 
 
 19 
 
 110 
 
 3 
 
 87 
 
 2 
 
 331 
 
 1 
 
 57 
 
 70 to 79 years. 
 
 10 
 
 69 
 
 9 
 
 69 
 
 8 
 
 143 
 
 1 
 
 13 
 
 1 
 
 74 
 
 1 
 
 746 
 
 • • • 
 
 • • • 
 
 SO years and over.. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Total . 
 
 1390 
 
 189 
 
 1005 
 
 161 
 
 592 
 
 192 
 
 413 
 
 130 
 
 385 
 
 354 
 
 205 
 
 385 
 
 180 
 
 325 
 
 same level to the end of life. The course of the morbidity- and mortality-rates 
 in these two groups is alike in that in both the rates for the female are higher 
 than those for the male in early life, and that the rates for female decline after 
 the third decade. In the white male the course of both rates is very similar 
 between the thirtieth and the fiftieth years. In the negro there is for both 
 sexes a striking correspondence in the shape of the curves for morbidity and 
 mortality for the different age-groups. In summary, it is to be observed in 
 the two races that for morbidity as for mortality the courses of the curves in 
 general are strikingly similar for females and somewhat similar for males. 
 These correspondences would probably be even closer if comparison could be 
 made for the same year and if the mortality data included the deaths occurring 
 in the extra-urban sanatoria. 
 
 The numerous factors which may have affected directly or indirectly the 
 incidence and mortality of tuberculosis in the 109 years under review will be 
 discussed as briefly as possible under population, eleemosynary agencies, gen- 
 
402 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 era! sanitation, specific measures of administrative control, and the influence 
 of other diseases. 
 
 Influence of population changes upon mortality from tuberculosis may be 
 conceived to have been exerted through rate of growth, changes in racial 
 composition, financial prosperity and depression, and the quantity and quality 
 of food. Taking pulmonary tuberculosis as the criterion for comparison, and 
 the data recorded in Chapter VIII for details in regard to population growth 
 and composition, it would appear that mere growth in numbers, determined 
 very largely during most of the nineteenth century by rate of immigration, 
 was not an important factor in the decline in the death-rate. The very high 
 death-rates obtaining in 1812 occurred in a city of about 50,000 inhabitants 
 after a prolonged period of an exceptionally high rate of increase, about 9 per 
 cent per annum, over a period of something more than 30 years, in the popula¬ 
 tion, and the marked decline in the rate between 1812 and 1840 took place 
 during a period of marked and steady decline in the rate of population in¬ 
 crease (table 9). On the contrary, the great rise in the death-rate from pul¬ 
 monary tuberculosis after 1840 and the culmination in 1855 followed a great 
 and sudden rise in the rate of population growth due to immigration, between 
 1840 and 1850, and perhaps for several years of the sixth decennium. 
 
 Coincidentally with the decided fall in the rate between 1855 and 1865, 
 and the practically stabilized death-rate obtaining between 1865 and 1880, 
 the rate of population increase had returned to a much lower level, main¬ 
 tained for three decades (1850 to 1880) at about 25 per cent or 2.5 per cent 
 per annum, approximately the same rate of increase which characterized 
 the decade between 1830 and 1840. The marked and steady decline in the 
 tuberculosis mortality which took place between 1880 and 1900 happened 
 in the face of an accelerated growth-period (30.7 per cent) in the first decade 
 and in the face of a retarded growth-rate (17.2 per cent) during the second 
 decade. On the other hand, the distinct check in the rate of decline of the 
 death-rate, amounting to almost a standstill, that occurred between 1900 and 
 1910, was associated with the very lowest rate of population increase (9.7 per 
 cent) recorded. Similarly with the rise in the rate of population growth to 
 13.8 per cent during the last decade, 1910-1920, the pulmonary tuberculosis 
 death-rate declined on the whole. It is clear that excessive rates of popula¬ 
 tion growth were definitely associated with high death-rates, that moderate 
 rates of population increase were accompanied by falling or stationary death- 
 rates, and that a very low rate of population increase was coincident with a 
 slight rise and then a slight fall in the death-rate, and, lastly, that a slight 
 increase of population growth was followed by a resumption in death-rate 
 decline. As any increase in the rate of population growth of over 1 per cent 
 or 1.4 per cent per annum in the Baltimore population is greater than the 
 natural increase by excess of births over deaths, and must, therefore, be due 
 to immigration, it is evident that there has existed a very definite relation 
 between high death-rates from pulmonary tuberculosis and the immigration 
 rate, i. e., the former have risen and fallen with the tide of the latter. There¬ 
 fore, it is here of prime importance to examine with some care such pertinent 
 characteristics of these immigrants as race stock, place of origin, previous 
 living and social conditions, and chances of financial and social success on and 
 after arrival. As these matters have been dealt with in detail in the chapter 
 
FEBRILE DISEASES 
 
 403 
 
 on population, it is only necessary here to bring together in condensed state¬ 
 ment the essential facts there recorded. 
 
 The high pulmonary tuberculosis death-rates of 1812 and the years imme¬ 
 diately succeeding affected a population of 78 per cent white and 22 per cent 
 negro. The whites were predominantly of British extraction and of colonial 
 descent, but with a considerable proportion of individuals of only the first 
 and second generation in this country. It is certain that the bulk of this ele¬ 
 ment could not have been city dwellers in either America or in Britain for 
 more than one generation, since but few American cities from which they 
 would have come had long been populous, and the trend here, as in Britain, 
 at that time was from rural to urban, and persons of this type well established 
 in one growing city would not in large numbers migrate to another. This 
 element formed the majority of the educated and wealthy citizenhood. The 
 considerable body of persons of French extraction were in the second genera¬ 
 tion and had become relatively prosperous, and the same conditions applied 
 to most of those of German extraction. Thus, whites of the relatively very 
 rich and thriving city, composed largely of stocks hardy and robust, drawn 
 from the country, could not in any large proportion have been inured to 
 city life. The wdiite population which had for three decades been increasing at 
 the rate of about 90 per cent, during the next three decades (1810-1840) in¬ 
 creased at a much less rapid rate—about 30 per cent per decade. 
 
 In 1810 the negro population was practically new to town and city life, the 
 10,343 then present had increased by 256 per cent between 1790 and 1800, and 
 grew by 84 per cent during the following decade. In the next three decades dur¬ 
 ing which the death-rate from pulmonary tuberculosis fell so sharply (graph 
 21), the negro population increased at a very much less rapid rate (42, 29, and 
 12 per cent, respectively), and between 1830 and 1840 but relatively slightly 
 from immigration, but in 1840, out of a population of 102,000, they formed 
 20 per cent. As during all this period their general death-rate had been much 
 higher than the white, it is probable that their death-rate from pulmonary 
 tuberculosis was, as it is known to have been in 1850, correspondingly higher. 
 The greater part of the negroes were free, and, though many of them were 
 probably relatively well to do, in comparison with the whites they were poor 
 and illy housed and inadequately fed. Therefore, during this period of decline 
 of the death-rate from pulmonary tuberculosis, roughly between 1820 and 
 1840, the most susceptible elements in the population, the negroes and the 
 other recent rural immigrants, were gradually decreasing numerically in im¬ 
 portance, and the older, more stable white population was in the same manner 
 running into more generations and becoming more inured to urban life and 
 perhaps to tuberculosis. The negro was undergoing the same process, but 
 with in each case a relatively greater distance to cover. 
 
 The fifth decade of the nineteenth century marked a radical change in both 
 the population composition and in the tuberculosis death-rate. While the 
 latter rose sharply and steadily after 1840 and reached a new high peak 15 
 years later, the population, which had, since 1830 at least, been receiving, 
 besides migrants of British extraction, considerable additions of Irish and 
 Germans—probably both in larger proportions from rural districts—during 
 and immediately following the fifth decade was augmented by the influx of 
 crowds of the latter two races, largely refugees from starvation or political 
 
404 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 oppression or both. In this decade the white population increased by 73 per 
 cent and the negroes expanded by 34 per cent, and by 1850 practically all the 
 negroes were free and had to shift for themselves. Thus there was in a com¬ 
 paratively short time a great growth in population, the new elements of 
 which were largely if not entirely destitute. 
 
 The overcrowding, the poverty, and the illness from various diseases, par¬ 
 ticularly small-pox, typhus fever, measles, and intestinal diseases, was exces¬ 
 sive. After 1850, for the next 40 years the white population increased at an 
 average rate of 2.7 per cent a year—31 per cent in the first and last and 23 and 
 22 per cent during the intermediate decades. Between 1850 and 1860 the 
 negro population showed both an actual and a large relative decrease. It 
 rebounded during the next decade with a 41 per cent increase, but its rate of 
 increase then sank gradually to 25 per cent for the decade 1881-1890. Since 
 1890 the negro, as well as the white population, has increased at slower rates. 
 The migration of Austrians, Bohemians, Poles, and Italians, among the 
 whites, since 1870, has brought in not only new races apparently more resis¬ 
 tant to tuberculosis than the Irish and Germans, but, by supplying great 
 additions to the group of manual laborers, has probably seriously restrained 
 immigration of negroes. These people, however, have come very largely from 
 villages and rural districts and have perhaps retarded rather than accelerated 
 any tendency to the fall of the tuberculosis death-rate among whites. They 
 arrived, however, in a period of prolonged and relatively high prosperity, 
 during which living conditions and wages have improved. On the other hand, 
 the German and Polish Jew populations, the former growing long and slowly 
 and the latter rapidly and only since 1884, representing a race or at least 
 races—for the strictly Semitic racial origin of the Polish Jew is questionable— 
 long inured to urban life and intimate associations with the disease, have 
 probably exerted an influence even more favorable upon the death-rate, par¬ 
 ticularly during the last 30 years. 
 
 It is difficult to determine the influence of prosperity and depression in 
 business upon the history of tuberculosis in such a composite and unwelded 
 population. The very high death-rates obtaining in the early years and last¬ 
 ing until 1820 occurred in the period of trade depression which preceded and 
 followed the war of 1812-1815. The considerable reaction in the rates which 
 took place between 1830 and 1835, after 10 years of sharp decline, synchro¬ 
 nized in time to some degree with the financial depression connected with 
 the fight over the national bank act. The rate which had fallen during the 
 10 years previous to 1865 remained almost stationary during the local finan¬ 
 cial depression following the Civil War period. During the period of the 
 return of relative prosperity which set in after 1880, there began the great 
 decline which lasted 20 years. However, in the almost equal stretch of years 
 1900 to 1918, with unexampled prosperity, there was practically no gain over 
 the forces of mortality. 
 
 Baltimore markets have, except during some years of the Civil War, never 
 lacked food in abundance and variety for those who could buy, so the question 
 of food-supply for the general population has been a relative one of wages 
 and of intelligence in selection and preparation of diet. The people, on the 
 whole, have throughout the period under consideration fared well in com¬ 
 parison with other communities, food having been relatively cheap and well 
 
FEBRILE DISEASES 
 
 405 
 
 prepared. It is probable that much less milk and milk products have been 
 utilized than would have been of advantage, but not less and perhaps more, 
 than in other cities. The records of the health department indicate that per 
 capita consumption of milk has greatly increased during the last 30 years. 
 
 It has been pointed in other chapters that Baltimore has never lacked chari¬ 
 table agencies, such as benevolent associations, homes for the aged and 
 orphans, and dispensaries and hospitals, by means of which the needy have 
 been cared for and the indigent sick treated. Until recent years cases of tuber¬ 
 culosis formed a conspicuous portion of the clientele of general dispensaries 
 and hospitals. They always received without stint, certainly in the dispen¬ 
 saries, the current orthodox medicines and general advice. General civic inter¬ 
 est in tuberculosis was aroused first, perhaps, by Dr. Osier. A special commis¬ 
 sion authorized by the legislature in 1902, under the chairmanship of Dr. 
 W. S. Thayer, rendered an exhaustive report. As a direct outcome of this, a 
 tuberculosis exhibition was held in January 1903. Under the leadership of 
 Drs. Welch, Osier, Thayer, Jacobs, Jones, Fulton, and numerous prominent 
 laymen, the Maryland Society for the Prevention of Tuberculosis was organ¬ 
 ized in 1904. It has been the center of anti-tuberculosis propaganda and has 
 been largely instrumental in securing all subsequent legislation on the subject. 
 The association has been a strong influence in securing the State Tuberculosis 
 Hospital (1908), the Municipal Hospital for advanced cases (1904), Eudo- 
 wood Sanatorium (1904), the Jewish Hospital for Consumptives, and the 
 Division of Tuberculosis of the city health department. Through the influ¬ 
 ence of Dr. Osier, the Phipps Tuberculosis Dispensary was established in con¬ 
 nection with the Johns Hopkins Hospital in 1904. 
 
 It is unnecessary to review here the history of the attempts at nuisance 
 control as applied to paving, street cleaning, sewage disposal, water, food, and 
 the like, which have been treated fully in previous chapters. Suffice it to recall 
 that the efforts in these directions in most respects were hopelessly inadequate 
 and could not have exerted any favorable influence until very recent years. 
 Striking declines in the tuberculosis death-rate took place under general sani¬ 
 tary conditions of the worst kind. It is possible that a gradual abandonment 
 brought about after 1880 of the use of water of wells and springs grossly 
 polluted with human excreta from cesspools and privies, and therefore poten¬ 
 tial carriers of tubercle bacilli, may have exerted a favorable influence upon 
 tuberculosis death-rates. The general water-supply could not have been heavily 
 laden with human, but was perhaps well seeded with bovine tubercle bacilli. 
 Too little is known of the fate of B. tuberculosis in polluted drinking-waters 
 to warrant stressing this point, particularly in a community in which infec¬ 
 tion would so readily occur by other means. 
 
 The development of small parks, never numerous except about the city 
 springs, in the closely built areas, hardly began before 1870, and the large 
 parks were not available at all to the great mass of the people until the devel¬ 
 opment of cable and electric traction in the last decade of the nineteenth cen¬ 
 tury. The same innovation was primarily responsible for the departure from 
 the old custom of substituting wide streets and separate houses in new develop¬ 
 ments, such as the northern margins of the city, for the old, closely built 
 blocks. However, the great mass of the people continued to dwell in the latter. 
 The housing and building laws of recent years were not retroactive, and were 
 
406 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 passed after , in certain parts of the city, whole blocks had become almost 
 solidly built up with dwellings, and family on family had been stacked in 
 what had been previously single-family dwellings. While, in the last 20 years, 
 many dwellings in alleys and courts have been condemned or improved, it is 
 not possible to determine with any accuracy whether, on the whole, the hous¬ 
 ing conditions of the great bulk of the population living in closely built areas 
 was any worse or any better in regard to crowding and lack of reasonable sun¬ 
 light and air, at any particular date between 1812 and 1900 during which 
 time the death-rates fell and rose again. Naturally, marked overcrowding 
 must have always succeeded excessively active immigration and have lasted for 
 some years until building operations caught up with the demand. But in 
 periods of fairly steady migration, construction and demand have closely 
 coordinated. 
 
 In this sense, excess in growth by immigration as before 1812 and in 1840- 
 1850 may have influenced the high rates obtaining by increasing the rates 
 among both migrants and indigenes. However, government regulations and 
 laws can not be shown to have exercised any material influence. The inspection 
 conducted by the tenement and lodging house division of the health department 
 since 1912 has undoubtedly improved the general cleanliness of dwellings of 
 this type. 
 
 The improvements in the milk-supply developed very gradually between 
 1894 and 1918, but except for the exclusion of milch cattle from the city, they 
 can not, until effective pasteurization was enforced in the latter year, be held 
 to have exerted any marked influence upon massive dosage of B. tuberculosis 
 on any considerable proportion of the population. The establishment of the 
 Walker-Gordon Milk Laboratory and the sterilization in private homes of 
 milk for babies and young children doubtless may have exerted a favorable 
 influence in this respect. On the whole, the amount of bovine bacilli taken by 
 the population must have been considerably, though very gradually, cut down 
 since 1900, due to the efforts of farmers, dealers, and the health department. 
 
 Butter has probably, through the same influence, become a less potent 
 vehicle for the transmission of bovine tubercle bacilli. Federal meat inspec¬ 
 tion may also have to some degree accomplished the same results in regard to 
 meats, but no such claim can be made for that instituted by the health 
 department. 
 
 The great advances in the diagnosis and treatment of tuberculosis of bones 
 and joints and of the cervical lymph-glands during the same period can hardly 
 have been without influence distinctly favorable, particularly upon the death- 
 rate for other forms of tuberculosis. 
 
 The growth of public and private measures of prophylaxis can hardly have 
 failed to exert a considerable influence by rendering less common than form¬ 
 erly opportunities for repeated massive infection with tubercle bacilli of the 
 human type determining attacks of tuberculosis running an acute course. 
 
 Administrative activities on the part of the health department, directed 
 specifically to the control of the spread of tuberculosis through measures affect¬ 
 ing persons and their immediate surroundings, began in 1896 and have devel¬ 
 oped leisurely and according to accepted canons but imperfectly. The first 
 measure, tentative and feeble, was the passage of an ordinance directing the 
 commissioner of health to keep a registry of cases of pulmonary tuberculosis 
 
FEBRILE DISEASES 
 
 407 
 
 and requesting physicians to report cases. The commissioner was, however, 
 forbidden to assume sanitary control of tuberculous persons, except on the 
 request of attending physicians, unless they were residents of tenements, 
 boarding-houses, or hotels. Sputum examinations, free of charge, were under¬ 
 taken by the newly established bacteriological laboratory the same year. But 
 few cases were registered except through the laboratory, and there was no 
 machinery provided for the supervision of the class of cases covered by the 
 ordinance. 
 
 Between 1900 and 1905, Dr. C. Hampson Jones made a number of statistical 
 and topographical studies on pulmonary tuberculosis in Baltimore, collaborated 
 actively with the tuberculosis commission authorized by the legislature in 1902, 
 and contributed largely to the success of a tuberculosis exhibition. It was by a 
 legislative enactment in 1904 that the reporting of cases of pulmonary tubercu¬ 
 losis by physicians and heads of institutions was made compulsory, and the 
 health department was required to fumigate the living quarters of known cases 
 of pulmonary tuberculosis after removal on account of death or other reasons, 
 and to furnish consumptives with sputum-cups, disinfectants, and printed 
 instructions in regard to prophylaxis. Physicians who cooperated with the 
 health department in the supervision of their consumptive patients were to 
 receive a small fee from the state. The law further provided that on the refusal 
 or neglect of the attending physician to cooperate, the function of oversight 
 of a consumptive devolved upon the health department. Except to inaugurate 
 in 1906 fumigation with formaldehyde gas of the living apartments of con¬ 
 sumptives after death, the Baltimore health department did nothing to carry 
 out the provisions of this law until 1910. The ordinance of 1905, forbidding 
 expectoration in streets and other public places, with the strong support of 
 jmblic opinion, was so effectively enforced by the police that by 1910 the 
 spitting nuisance was effectively controlled. 
 
 Under the general supervision of Assistant Commissioner Jones, a division 
 of tuberculosis was established in the health department on January 1, 1910. 
 The simple organization consisted of 14 trained nurses, under the direction 
 of a superintendent of nurses, of experience, intelligence, and force. For 
 administrative purposes the city was divided into 14 districts, to each of which 
 a nurse was assigned. The new division took over at once 1,617 cases of 
 pulmonary tuberculosis from the Visiting Nurses* Association, an ably man¬ 
 aged organization which had for 6 years, in addition to its other work, cared 
 for needy tuberculous patients. In many respects this innovation signified 
 only that the health department superseded a private organization in the 
 nursing care of a large number of cases of pulmonary tuberculosis. In the 
 very important respect, however, that the public-health nurses were in larger 
 force and acted under the authority of the health department, conditions were 
 materially changed. In regard to giving advice and instructions to ambula¬ 
 tory cases, nursing care to bedridden cases, and assistance in gaining admission 
 to sanatoria and to the Municipal Hospital, there were no important changes. 
 The chief innovations immediately introduced were the supervision of many 
 more cases, the supplying of sputum-cups, paper napkins, and disinfectants, 
 the giving of more specific advice in regard to mode of life and changes in 
 home surroundings and in vocation, the arranging to have all members of 
 families of tuberculosis patients submit to expert medical examination, the 
 
408 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 selecting of the most suitable cases for sanatoria and the Municipal Hospital 
 for advanced cases, and finally, the arranging for the fumigation of rooms, 
 sterilization of infected clothing and bedding, and the insisting upon the 
 cleaning and airing of the dwellings of “ open ” cases of pulmonary tubercu¬ 
 losis. In 1912, 2 more nurses were added to the division and in 1917 the 
 number of nurses was increased to 20. Two dispensaries were opened in 1912 
 and an additional one in 1916. The principles of action of Miss LaMotte, the 
 first superintendent of nurses, as set forth in her first two annual reports, were 
 simple and direct. As the primary work of the health department was to 
 minimize infection, it was most important to control advanced cases. To those 
 for whom hospitalization could not be had, frequent visits of instruction and 
 oversight must be made. Though a close working relation was maintained with 
 charitable organizations, to which the needy were often referred for relief, 
 special diet was never to be requested for the tuberculous unable to buy it, 
 because of the premium that would be set upon their remaining at home. All 
 comfort and relief afforded to individuals was regarded as only incidental. 
 
 “ Our function is to try to reduce the amount of tuberculosis in the community, and 
 
 this is best done by concentrating our efforts on care of the last-stage case.The 
 
 object of the division is to bring under supervision every case of pulmonary tuberculosis 
 in the city. Many require little beyond advice, supplies, and general instructions. Bed¬ 
 ridden cases require nursing care, and it is upon these and their contacts that chief 
 effort is concentrated.” 
 
 In connection with a request for special tuberculosis dispensaries in 1911, 
 she wrote 
 
 “ The chief, almost the only value of the dispensary lies in its being a 
 diagnosis agency; treatment amounts to practically nothing.” 
 
 The physician in charge of the department’s tuberculosis dispensaries has 
 acted on this principle. Cases found positive are advised to go to sanatoria, 
 and if this can not be accomplished, the association with the dispensary usually 
 ceases. Neither the methods of procedure nor the ideas underlying them have 
 undergone material changes in 10 years. 
 
 A general idea of the activities of the division of tuberculosis and of the 
 sources of the cases reached and of their disposal during the 11-year period 
 1910-1920, may be obtained from table 88, which was compiled from the 
 annual reports of the superintendent of nurses. Owing to changes in the forms 
 of these reports specific information under some of the headings is lacking 
 in the later years. The figures in column 1 represent the total number of 
 persons recorded in the visiting-list in each calendar year as either positive 
 or suspicious cases of pulmonary tuberculosis. They do not include, however, 
 the large number of persons who, on account of household association with posi¬ 
 tive or suspicious cases, were taken by the nurses to dispensaries for medical 
 examination. These are included in the group “ Referred to dispensaries.” 
 Owing to the uncertain duration of their stay, patients in sanatoria have been 
 kept on the visiting-lists until death or recovery. In but few years are there 
 references to cases discharged for the latter reason. It will be noted that the 
 number of individuals annually on the lists increased very gradually between 
 1910 and 1916, and, then, after remaining nearly constant for 3 years fell 
 considerably in 1920. 
 
FEBRILE DISEASES 
 
 409 
 
 Death was invariably the chief cause for loss of names from the list, but the 
 annual losses due to removals from the city and to changes of address were con¬ 
 siderable. Of less and continuously decreasing importance were losses due to 
 the discharge of suspicious cases as non-tuberculous. This change was largely 
 the result of the growth in discrimination in the light of experience. The 
 number of cases on the list at the end of each calendar year (column 6) 
 represents the difference between the whole number listed (column 1) and 
 the net losses (column 2). The figures in column 6 indicate in a rough way 
 the approximate number of individuals on the visting-lists at any time in the 
 several years known or thought to have pulmonary tuberculosis. This number 
 grew very steadily from 2,416 in 1910 to 4,702 in 1916. Since the latter date 
 the number of persons constantly under supervision was not far from 5,000. 
 During the period in wdiich they were separately recorded, the proportion of 
 suspicious to positive cases steadily declined. In columns 9 and 10 are given 
 the numbers of new and old cases listed in each year. The number of new 
 cases added to the lists in no year corresponds with the number of cases 
 officially reported (compare with table 85). These discrepancies are due to 
 the acts of private physicians in withholding permission to visit entirely or 
 for a longer or shorter time after reporting cases. Similarly, under sources 
 of reported cases, the figures in column 11 indicate only the numbers of cases 
 reported by physicians for which permission to visit was granted in any par¬ 
 ticular year. 
 
 It will be noted that since 1916, as the division of tuberculosis has gained 
 the confidence of the physicians, an increasingly large proportion of the 
 reported cases appear on the visiting lists. However, in later years it is 
 evident that less than half of the reported cases of pulmonary tuberculosis 
 could have been under the care of private physicians. The relatively impor¬ 
 tant part played by the Phipps Dispensary, which since 1904 has superseded, 
 in regard to pulmonary tuberculosis, the medical clinic of the Johns Hopkins 
 Hospital, reflects in part the reputation of the hospital. The tuberculosis 
 clinic of the University of Maryland as a branch of the medical clinic of the 
 University Hospital, and the three dispensaries of the health department have 
 contributed comparatively lightly to the whole number of reported and listed 
 cases. Under the heading “ other sources ” are included the numerous gen¬ 
 eral dispensaries and various charitable organizations. Under hospitalization 
 the table shows all the known, data in regard to hospital care, both for 
 isolation and for cure, given at public expense. Here, however, no account 
 is taken of cases received in general hospitals for longer or shorter periods, 
 nor for the many cases, particularly among the well-to-do, that have gone to 
 distant resorts. To the Municipal Hospital have been sent only advanced and 
 hopeless cases selected from among many claimants by the nurses as particularly 
 dangerous to their families. Relatively few who enter this institution leave 
 alive. It will be noted that the number of annual admissions—about 300 
 between 1910 and 1917—greatly decreased in the last 3 years. At Eudowood 
 Sanitorium, where 30 of the 70 beds are reserved for advanced cases, the 
 admission-rate has fallen off since 1916. The high level of admission to the 
 Jewish Hospital was reached in 1914 and 1915; since the latter year the 
 admission-rate has greatly declined. 
 
410 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 The annual admissions to the State Sanatorium, reserved for incipient and 
 moderately advanced cases, increased in number almost uninterruptedly from 
 107 in 1908 to 479 in 1917, but since the latter date there has been even here 
 a slight falling off. The highest point in hospitalization was reached in 1915, 
 with 321 admissions to the Municipal Hospital and 656 to the three sanatoria. 
 By 1920 these figures had fallen to 130 and 566, respectively. Under admis¬ 
 sions to other sanatoria are included the relatively few cases reported by 
 nurses as having gone to distant resorts. These belong to the class for whom 
 permission to visit is rarely granted. Among the patients sent to the three 
 extra-urban sanatoria between 1913 and 1920, the years for which records of 
 deaths among them have been kept, the fatality-rate varied from 10 to 23.5 
 per cent. In other words, of the picked cases sent to curative sanatoria, on an 
 average over 17 per cent died while in these institutions. The proportion 
 of deaths occurring among those who returned to the city is unknown. The 
 activity of the nursing force in the various years, as measured by the number 
 of visits paid, fumigations of dwellings supervised, persons sent to dispen¬ 
 saries, and new cases apprehended, is indicated in columns 25, 26, 27, and 28 
 of table 88. It will be observed that the greatest number of visits paid in any 
 one year was 87,102 in 1917, when a total of 6,645 persons were under observa¬ 
 tion. The number of fumigations supervised varied with the numbers of 
 deaths and the movings of recorded living cases. 
 
 The reports contain some data throwing light upon various phases of the 
 tuberculosis problem in Baltimore and on the value of the efforts exerted for 
 its solution. According to Miss LaMotte’s analysis of the 3,107 positive and 
 suspicious cases of pulmonary tuberculosis on the visiting-lists on December 
 31, 1912, 20 per cent were recipients of charitable aid. She estimated that a 
 possible additional 20 per cent were on the verge of need of such assistance. 
 At least 50 per cent of the cases were well beyond want. Many of these “ live 
 in excellent houses and are far removed from the dire poverty, overcrowding, 
 and unsanitary quarters usually considered to play such a great part in the 
 spread of tuberculosis.” In 608, or 19 per cent of the houses, the patients 
 conducted some sort of small industry, the chief types being laundries, 222; 
 boarding-houses, 104; sewing, 104; lodgings, 18; shoemaking, 21. 
 
 An analysis of the positive cases on the visiting-lists on December 31, 1915, 
 in regard to stage of the disease, ability to work, and response to instruction 
 is probably typical of other years. In respect of stage of the disease, of the 
 3,606 cases, there were classed as incipient 107 (2.9 per cent), moderately 
 advanced 1,981 (54.9 per cent), advanced 752 (20.9 per cent), chronic 405 
 (11.2 per cent), arrested 361 (9.1 per cent). Of the whole number under 
 observation, 569 were hospitalized and 3,037, or more than 80 per cent, were in 
 their homes. According to physical capacity, there were able to work full 
 time, 1,838; part-time, 715; unable to work but not confined to bed, 391. 
 Only 93 were bedridden. In regard to amenability to instruction for the 
 protection of associates, the 3,245 active cases were classified as adequately 
 careful, 548; moderately careful, 1,322; careless, 1,375, or in the proportion, 
 of 17, 41, and 42 per cent respectively. 
 
 In any scheme for the prevention of tuberculosis by control of cases of the 
 disease it is of capital importance that cases be recognized and reported in 
 their early stages. The degree in which this essential condition has been met 
 
FEBRILE DISEASES 
 
 411 
 
 Table 88. —Administrative activities directed toward the control of tuberculosis, from 
 
 1010 to 1920, inclusive. 
 
 Recorded cases. 
 
 Cases reported by— 
 
 Year. 
 
 Total number of per¬ 
 sons on list. 
 
 Losses. 
 
 Cases listed at end 
 of year. 
 
 New cases. 
 
 Old cases returned. 
 
 Physicians. 
 
 Phipps Dispensary. 
 
 University of Maryland 
 
 dispensary. 
 
 Health department dis¬ 
 
 pensaries. 
 
 Tuberculosis nurses. 
 
 Other sources. 
 
 Total. 
 
 By death. 
 
 By removal, etc. 
 
 Non-tuberculous. 
 
 Total. 
 
 Positive. 
 
 Suspicious. 
 
 
 1 
 
 a 
 
 S 
 
 4 
 
 5 
 
 6 
 
 7 
 
 8 
 
 9 
 
 10 
 
 11 
 
 12 
 
 13 
 
 14 
 
 15 
 
 16 
 
 1910 . 
 
 4251 
 
 1835 
 
 776 
 
 620 
 
 439 
 
 2416 
 
 1967 
 
 449 
 
 2591 
 
 43 
 
 432 
 
 431 
 
 107 
 
 
 706 
 
 915 
 
 1911 . 
 
 4319 
 
 1547 
 
 814 
 
 484 
 
 249 
 
 2772 
 
 2225 
 
 547 
 
 1816 
 
 87 
 
 349 
 
 391 
 
 83 
 
 • • • 
 
 358 
 
 625 
 
 1912 . 
 
 4743 
 
 1636 
 
 856 
 
 611 
 
 169 
 
 3107 
 
 2522 
 
 585 
 
 1892 
 
 79 
 
 382 
 
 418 
 
 58 
 
 27 
 
 251 
 
 756 
 
 1913 . 
 
 4985 
 
 1585 
 
 867 
 
 566 
 
 152 
 
 3400 
 
 2728 
 
 672 
 
 1777 
 
 101 
 
 328 
 
 406 
 
 70 
 
 62 
 
 214 
 
 697 
 
 1914 . 
 
 5192 
 
 1535 
 
 838 
 
 495 
 
 202 
 
 3729 
 
 3181 
 
 548 
 
 1704 
 
 88 
 
 286 
 
 439 
 
 39 
 
 133 
 
 157 
 
 650 
 
 1915 . 
 
 5600 
 
 1359 
 
 853 
 
 447 
 
 59 
 
 4175 
 
 3606 
 
 589 
 
 1759 
 
 112 
 
 421 
 
 404 
 
 61 
 
 97 
 
 113 
 
 663 
 
 1916 . 
 
 6135 
 
 1425 
 
 980 
 
 403 
 
 41 
 
 4702 
 
 9 
 
 9 
 
 1859 
 
 101 
 
 606 
 
 ? 
 
 9 
 
 132 
 
 9 
 
 ? 
 
 1917 . 
 
 6645 
 
 1764 
 
 1086 
 
 644 
 
 34 
 
 4881 
 
 4275 
 
 606 
 
 1869 
 
 74 
 
 682 
 
 9 
 
 9 
 
 134 
 
 9 
 
 9 
 
 1918 . 
 
 6665 
 
 1672 
 
 1176 
 
 482 
 
 14 
 
 4493 
 
 9 
 
 9 
 
 1767 
 
 17 
 
 765 
 
 214 
 
 20 
 
 64 
 
 64 
 
 340 
 
 1919 . 
 
 6613 
 
 1755 
 
 936 
 
 791 
 
 28 
 
 4858 
 
 9 
 
 9 
 
 1575 
 
 45 
 
 670 
 
 243 
 
 25 
 
 62 
 
 9 
 
 575 
 
 1920 . 
 
 6317 
 
 1596 
 
 872 
 
 703 
 
 21 
 
 4721 
 
 9 
 
 9 
 
 1418 
 
 41 
 
 633 
 
 151 
 
 22 
 
 96 
 
 20 
 
 496 
 
 Hospitalization. 
 
 Nursing activities. 
 
 Year. 
 
 Municipal hospital. 
 
 State sanatorium. 
 
 Eudowood sanatorium. 
 
 Jewish Sanatorium. 
 
 Other sanatoria. 
 
 Patients admitted to state 
 sanatorium, Eudowood, and 
 Jewish Sanatorium. 
 
 Number of deaths. 
 
 Percentage, case fatality. 
 
 Referred to dispensaries. 
 
 Total number of visits by 
 nurses. 
 
 Houses fumigated after death 
 of patients. 
 
 Houses fumigated after re¬ 
 moval of patients. 
 
 
 17 
 
 18 
 
 19 
 
 20 
 
 21 
 
 22 
 
 2® 
 
 24 
 
 25 
 
 26 
 
 27 
 
 28 
 
 1910 . 
 
 339 
 
 107 
 
 79 
 
 25 
 
 
 211 
 
 
 
 2903 
 
 
 1162 
 
 1742 
 
 1911 . 
 
 291 
 
 109 
 
 109 
 
 33 
 
 • • • • 
 
 251 
 
 • « • • 
 
 • • • • 
 
 1917 
 
 61195 
 
 1186 
 
 2011 
 
 1912 . 
 
 310 
 
 180 
 
 123 
 
 53 
 
 • • • • 
 
 356 
 
 • • • • 
 
 • • • • 
 
 3082 
 
 72058 
 
 1157 
 
 1769 
 
 1913 . 
 
 298 
 
 295 
 
 116 
 
 61 
 
 • • • • 
 
 472 
 
 72 
 
 15.3 
 
 3375 
 
 79743 
 
 1107 
 
 2186 
 
 1914 . 
 
 286 
 
 365 
 
 105 
 
 94 
 
 1 
 
 564 
 
 83 
 
 14.7 
 
 2785 
 
 82726 
 
 1110 
 
 2264 
 
 1915 . 
 
 321 
 
 464 
 
 98 
 
 94 
 
 14 
 
 656 
 
 66 
 
 10.1 
 
 2618 
 
 75773 
 
 1042 
 
 2388 
 
 1916 . 
 
 286 
 
 443 
 
 105 
 
 60 
 
 13 
 
 608 
 
 111 
 
 18.3 
 
 2141 
 
 83907 
 
 1288 
 
 2250 
 
 1917 . 
 
 308 
 
 479 
 
 83 
 
 68 
 
 14 
 
 630 
 
 125 
 
 19.8 
 
 3012 
 
 87102 
 
 1100 
 
 1903 
 
 1918 . 
 
 175 
 
 438 
 
 96 
 
 53 
 
 9 
 
 587 
 
 138 
 
 23.5 
 
 1637 
 
 82528 
 
 4457 
 
 1919 . 
 
 160 
 
 475 
 
 78 
 
 63 
 
 5 
 
 616 
 
 131 
 
 21.4 
 
 1796 
 
 76505 
 
 1897 
 
 1920 . 
 
 130 
 
 422 
 
 92 
 
 52 
 
 30 
 
 566 
 
 85 
 
 15.0 
 
 999 
 
 71848 
 
 1649 
 
 1 
 
 27 
 
412 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 will be indicated by determining among reported cases the interval of time 
 elapsing between the dates of reporting and death. According to an analysis 
 by Miss LaMotte, in 1912, of the 1,189 deaths from pulmonary tuberculosis 
 in the city, 856 were among cases on the visiting-lists. Among these 856, 
 
 deaths occurred within— 
 
 1 month after reporting. 188 or 22 per cent. 
 
 First and second month after reporting. 115 or 13.4 per cent. 
 
 Second and third month after reporting. 68 or 8 per cent. 
 
 Third and fourth month after reporting. 73 or 8.5 per cent. 
 
 Within 4 months after reporting. 444 or 51 per cent. 
 
 Within 1 year after reporting. 635 or 77 per cent. 
 
 Within first and second year after reporting. 114 or 13 per cent. 
 
 Within second and third year after reporting. 87 or 10 per cent. 
 
 These figures were thought to support the claim of the nurses that report¬ 
 ing was not only delayed, but very incomplete. 
 
 At the instance of the writer, in 1916, the deaths from pulmonary tuber- 
 losis which occurred during that year among cases upon the visiting-lists were 
 analyzed according to the time which elapsed since they were reported. The 
 results are presented in tables 89 and 90. The 980 cases analyzed included the 
 
 Table 89. —Distribution of deaths in 1916 from pulmonary tuberculosis, according to 
 
 years in which the decedents were reported as cases. 
 
 Years. 
 
 Total. 
 
 White. 
 
 Colored. 
 
 No. of cases 
 dying. 
 
 Per cent of 
 total. 
 
 No. of cases 
 dying. 
 
 Per cent of 
 total. 
 
 No. of cases 
 dying. 
 
 Per cent of 
 total. 
 
 1910 . 
 
 35 
 
 3.6 
 
 31 
 
 4.6 
 
 4 
 
 1.3 
 
 1911 . 
 
 13 
 
 1.3 
 
 9 
 
 1.3 
 
 4 
 
 1.3 
 
 1912 . 
 
 31 
 
 3.1 
 
 29 
 
 4.3 
 
 2 
 
 0.7 
 
 1913 . 
 
 50 
 
 5.0 
 
 44 
 
 6.6 
 
 6 
 
 1.9 
 
 1914 . 
 
 70 
 
 7.1 
 
 56 
 
 8.4 
 
 14 
 
 4.5 
 
 1915 . 
 
 282 
 
 28.8 
 
 208 
 
 31.0 
 
 74 
 
 24.0 
 
 1916 . 
 
 498 
 
 50.8 
 
 293 
 
 43.7 
 
 205 
 
 66.3 
 
 Total . 
 
 980 
 
 100 
 
 671 
 
 100 
 
 309 
 
 100 
 
 Table 90. —Time elapsing between data of report and date of death of cases of pulmonary 
 
 tuberculosis reported and dying during 1916. 
 
 Time. 
 
 Total. 
 
 White. 
 
 Colored. 
 
 No. of cases 
 dying. 
 
 Per cent of 
 total. 
 
 No. of cases 
 dying. 
 
 Per cent of 
 total. 
 
 No. of cases 
 dying. 
 
 Per cent of 
 total. 
 
 Under 1 week. 
 
 73 
 
 14.8 
 
 43 
 
 14.7 
 
 30 
 
 14.9 
 
 Between 1 and 2 weeks 
 
 59 
 
 11.9 
 
 34 
 
 11.6 
 
 25 
 
 12.4 
 
 Between 2 and 4 weeks 
 
 91 
 
 18.4 
 
 47 
 
 16.0 
 
 44 
 
 21.8 
 
 1 to 2 months. 
 
 94 
 
 19.0 
 
 48 
 
 16.4 
 
 46 
 
 22.8 
 
 2 to 3 months. 
 
 57 
 
 11.5 
 
 29 
 
 9.9 
 
 28 
 
 13.9 
 
 Under 3 months. 
 
 374 
 
 75.6 
 
 201 
 
 68.6 
 
 173 
 
 85.8 
 
 3 to 4 months. 
 
 43 
 
 8.7 
 
 32 
 
 10.9 
 
 11 
 
 5.5 
 
 4 to 6 months. 
 
 46 
 
 9.3 
 
 33 
 
 11.3 
 
 13 
 
 6.4 
 
 Under 6 months. 
 
 463 
 
 93.6 
 
 266 
 
 90.8 
 
 197 
 
 97.7 
 
 6 to 9 months. 
 
 28 
 
 5.7 
 
 23 
 
 7.9 
 
 5 
 
 2.5 
 
 9 to 12 months. 
 
 4 
 
 0.8 
 
 4 
 
 1.4 
 
 
 
 Total . 
 
 495 
 
 100 
 
 293 
 
 100 
 
 202 
 
 100 
 
FEBRILE DISEASES 
 
 413 
 
 deaths occurring among listed cases at the three extra-urban sanatoria. It 
 will be observed (table 89) that 50.8 per cent of the deaths were among cases 
 reported during 1916 and 28.8 per cent among cases reported in 1915, leaving 
 slightly over 20 per cent reported as cases during the remaining 5 years from 
 1910 to 1914, inclusive. Among this latter group, the proportions which had 
 been reported in each particular year steadily diminished from 1914 to 1911. 
 As between whites and negroes, the proportions as expressed in percentages 
 were 43.7 and 66.3 for 1916, and 31 and 24, respectively, for 1915. It is note¬ 
 worthy that of individuals dying in 1916, a very much larger percentage 
 among whites than among negroes had been reported as cases in previous years. 
 
 Considering now the 495 deaths that occurred among cases reported during 
 1916 (table 90), it is found that in a large proportion of instances death took 
 place within a few weeks after reporting. In over 75 per cent the cases had 
 been reported only 3 months, and in 93.6 per cent only 6 months before death. 
 The period elapsing between reporting and death was uniformly shorter for 
 negroes than for whites. The number of deaths between the sixth and the 
 twelfth month after reporting was insignificant. Considered alone, the data 
 in. table 90 suggest very strongly that case reporting was, as claimed by the 
 nurses, in many instances willfully delayed, with the result that many cases 
 of pulmonary tuberculosis were brought under observation and instruction 
 much later than the law contemplated. In support of this point there are two 
 main arguments: First, that there is strong circumstantial evidence that some 
 physicians have in certain instances delayed case reporting until it was evi¬ 
 dent that a fatal issue must soon ensue and further concealment would expose 
 them to prosecution when a certificate for death of an unreported case of 
 pulmonary tuberculosis was presented; second, that both in general and in 
 comparison with certain other cities (New York and Manchester, for instance) 
 the morbidity-rates as compared with the mortality-rates are relatively low. 
 In reply to these it is to be said, that such instances of willfully delayed 
 reporting are relatively rare; the majority of all cases are not reported by 
 physicians, but by dispensaries and other charitable agencies where the motive 
 for concealment is lacking; the proportion of early deaths after reporting is 
 higher in negroes, among whom the great mass of cases are reported by such 
 agencies and not by private physicians; since 1916, at least, physicians have 
 withheld consent to visit in but a small proportion of cases reported by them; 
 and for over 5 years the city had been dragnetted for cases of tuberculosis 
 by the health department nurses and by charitable agencies and but a very 
 small proportion of the large number of contacts with known cases submitted 
 to medical examination were proved to be clinical cases of tuberculosis. 
 
 In the light of these considerations more adequate explanation must be 
 sought. Since it is clear that the phenomenon under discussion can not, in 
 the nature of the case, in any considerable measure be due to willfully 
 delayed reporting, its true explanation must be sought in the natural history 
 of the disease and the reaction of its victims. In the discussion of the morbidity- 
 curve two significant points pertinent in this connection were established, 
 namely, that, since 1910, recognized cases must have been reported with a 
 fair degree of completeness and morbidity- and mortality-rates have had such 
 a constant ratio to each other that their simultaneous rise and fall must be 
 due to the operation of the same cause or causes. It appears from tables 89 and 
 
414 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 90 that the time elapsing between case reporting and death is conspicuously 
 shorter for negroes than for whites, and it is well established that the morbidity- 
 and mortality-rates were higher and the disease on the whole runs a shorter 
 course in the former than in the latter. It was found that on a particular 
 day in 1915 the “ advanced-stage ” group constituted 21 per cent of the whole 
 number of listed positive cases. It may be safely assumed that on an average 
 from 18 to 25 per cent of all registered cases fall in this category, and it is 
 evident that it is from this group that the bulk of the fatal cases must come. 
 The group “ advanced-stage ” reported cases can originate in only two ways, 
 either by decline from the stage next above, the “ moderately advanced stage,” 
 or by entering the lists as “ advanced-stage ” cases at the time of reporting. 
 The movement of moderately advanced cases is slow, and cases of this group 
 remain stationary, become arrested, become chronic, or go into the “ advanced 
 stage.” Those that pursue the latter course are the less resistant and probably 
 usually change from the higher to the lower stage shortly after being re¬ 
 ported. The numbers of the “ advanced-stage 99 group reported in this stage of 
 the disease may represent either cases of phthisis florida, or the not small class 
 of persons with pulmonary tuberculosis in moderately advanced stages without 
 clinical symptoms definite enough to cause them to seek medical advice until 
 after a sudden decline in health, when the disease has rapidly reached the 
 advanced stage. 
 
 When the question is considered in the light of the ascertained facts and 
 the inferences that flow from them, it becomes evident that in the nature of 
 the case, in a large proportion of instances of fatal pulmonary tuberculosis 
 death should occur within a comparatively short period after case reporting. 
 Here is brought into prominence a fundamental fact only too frequently 
 ignored by the untrained, namely, that there is often a vast difference between 
 the date of real incidence and the date at which a case of phthisis is likely 
 to attain the stage of reporting. On the whole, it seems probable that in the 
 period under review a very considerable proportion of those who developed 
 active pulmonary tuberculosis have not, for one reason or another, exposed 
 themselves to the conditions that lead to diagnosis and reporting until the 
 disease is well advanced, and that the relatively low recorded morbidity-rate 
 as compared with the mortality-rate has been due to this circumstance rather 
 than to neglect on the part of physicians to report their cases promptly. In 
 view of the failure of the active measures directed over so many years to the 
 earlier recognition of the disease, it is unlikely that anything short of com¬ 
 pulsory physical examination, repeated at short intervals, of every individual 
 in the community would materially change the recorded incidence of the 
 disease. 
 
 It has long been held by physicians that attacks of certain acute infectious 
 diseases, notably measles, scarlet fever, whooping-cough, typhoid fever, and 
 pneumonia, predispose to tuberculosis. In a general way, the mortality-rates 
 for tuberculosis, and for all of these diseases except pneumonia, have declined 
 together since 1880. To the degree that lowered death-rates indicate either 
 decreased incidence of these diseases or slighter injury to those who survive 
 attacks, it is possible that this association may he significant. On a parity of 
 reasoning, the decline and practical disappearance during this period of small¬ 
 pox and malaria and typhus fever, all of which severely tax the system, may 
 
FEBRILE DISEASES 
 
 415 
 
 have exerted a favorable influence upon the tuberculosis-rate. The period 
 of high mortality for pulmonary tuberculosis between 1840 and 1880 was 
 characterized by high rates for nearly all of these diseases. On the other 
 hand, the fall in the rates for pulmonary tuberculosis which took place between 
 1820 and 1840 occurred when the rates for the insect-borne diseases were par¬ 
 ticularly high, though falling. There is a distinct though not uniform cor¬ 
 respondence in the curve of the rates for tuberculosis and the diarrhceal 
 diseases, and particularly for those for dysentery and cholera. The curves for 
 pneumonia and pulmonary tuberculosis do not in general correspond very 
 closely. 
 
 What effects upon the morbidity- and mortality-rates may be attributed to 
 the specific efforts put forth by administrative authority? As judged by the 
 mortality-rate, there was no appreciable effect. The total death-rate was lower 
 in 1899 before anything was done than it was in any year until 1915. After 
 1899 there was a moderate wave of increase in the rates, which, reaching 
 a peak in 1904, had in its decline attained by 1910 the level of 1900. The 
 anti-spitting law can hardly be given the credit for this slight reaction. During 
 the first 4 years of the existence of the tuberculosis division, the mortality- 
 rate, when the deaths among Baltimore cases dying at the extra-urban sanatoria 
 are taken into account, remained practically on a level. The slight drop in 
 1915 to the level of 1899 was not maintained. In spite of additional nurses 
 and increased activity during the next 3 years, the rate rose steadily to the 
 level of 1905, or to a point nearly as high as was attained at the peak of the 
 last wave, and considerably higher than in 1899. Upon case reporting legal 
 enactments had but small effect until the establishment of the tuberculosis 
 division in 1910. It has been shown that the enormously high morbidity- 
 rates recorded between 1910 and 1912 were due to the registration of large 
 numbers of cases previously known and in no proper sense represented actual 
 current newly recognized cases. The morbidity-curve, which since 1913 may 
 justly be regarded as representing the current morbidity as judged by the 
 standard of reporting in vogue, rises and falls in strict consonance with the 
 curve for mortality. The sudden fall in both mortality- and morbidity-rates 
 since 1918, a duplication of a phenomenon characteristic of many American 
 cities since the great influenza epidemic, can hardly be attributed to the anti¬ 
 tuberculosis activities. Mortality-rates in Baltimore have moved in the same 
 manner, though in less degree, after other influenza epidemics. These occur¬ 
 rences suggest the query, whether an attack of influenza does not protect against 
 tuberculosis. 
 
 In the period 1910-1918, the nursing force had charge of from two-thirds 
 in the early period to four-fifths in the latter period of all known cases of the 
 disease for instruction in prophylaxis. During much of the period not less 
 than 15 nor more than 20 per cent of the cases of the moderately advanced 
 and something like 30 per cent of the cases of the advanced stage were hos¬ 
 pitalized, the former for curative treatment and the latter for isolation alone. 
 So far as benefits derived from instruction in prophylaxis are concerned, of 
 the active cases on the visiting-lists in 1915, a typical year, 17 per cent were 
 recorded as adequately careful, 41 per cent as moderately careful, and 42 per 
 cent as careless. In nearly half the cases the results of instruction were 
 regarded as nihil. It is safe to assume that the cases remaining exclusively 
 
416 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 under the instruction of their attending physicians were, on the whole, super¬ 
 vised and instructed at least as thoroughly and conscientiously as were those 
 visited by the nurses. Nor can prophylactic effects of any considerable value 
 be expected from fumigations of dwellings at the termination of the illness 
 or on removal of individuals, who for weeks, months, or even years had been 
 emitting myriads of tubercle bacilli daily. 
 
 It is evident from table 88 that the part played by the tuberculosis dispen¬ 
 saries of the health department in diagnosis and treatment was relatively 
 negligible. The only other special dispensaries for tuberculosis during this 
 period, Phipps and the University of Maryland, represented after all only 
 separate divisions of medical clinics long in operation. Similarly, the opening 
 of the Municipal Tuberculosis Hospital on Bay View grounds did not amount 
 to a great deal more than the segregation in a separate building of about the 
 same annual number of advanced cases of pulmonary tuberculosis that in 
 former years was received in the almshouse and infirmary of the same insti¬ 
 tution. The three extra-urban sanatoria were indeed new institutions opened 
 since 1908. Adequate data for measuring accurately their influence upon the 
 course of pulmonary tuberculosis in Baltimore are not available. An average 
 annual hospital death-rate of 17 per cent among the selected cases admitted 
 does not suggest that their favorable influence was striking. 
 
 In regard to other forms of tuberculosis from 1875 when the classification 
 of deaths under this heading first approached accuracy, the averaged rates 
 for the whole population fell steadily until 1895. During the next 5 years 
 they reacted to a somewhat higher level, which was maintained with slight 
 variations until 1920. In the 20-year period from 1901 to 1920, on the whole, 
 the rates for whites declined and those for negroes rose. The rates for females 
 were distinctly lower than those for males in both races. The rates for this 
 rubric declined sharply after the influenza epidemic. There was no significant 
 response to the sanitary improvements which characterized this period, unless 
 some of the decline since 1918 may be attributable to the pasteurization of the 
 milk-supply. So far as may be judged from the data at hand, the action of the 
 force of mortality in tuberculosis of the lungs and of other organs was strik¬ 
 ingly similar. 
 
 Advances and declines in the death-rates for the population as a whole have 
 been influenced less by rapid growth in the population per se than by changes 
 in the relative proportions of certain race stocks. The mortality-rate has been 
 considerably higher in negroes than in whites and has risen with the increase 
 and fallen with the decrease in the proportion of Irish and Germans in the 
 population. The rate has declined notably with the influx of Jews, Italians, 
 and Poles. The evidence that the mortality-rate was influenced by financial 
 depression and by prosperity is conflicting. On the whole, the balance of the 
 evidence is in favor of the view that it was unfavorably affected by financial 
 depression. It is more than possible that increase in the quantity of the milk- 
 supply since 1880 may have exerted a favorable influence. Whereas the 
 mortality-rate did decline synchronously with sanitary improvements at certain 
 times, e. g., after the water-supply, sewerage disposal, paving, and the like had 
 undergone distinct improvements between 1820 and 1840, and the water- 
 supply again after 1865, and after 1880, this must apparently be attributed 
 to other causes, for there was, on the whole, no significant decline in the annual 
 mortality-rates in this period from 1900 to 1918, during which time the most 
 
FEBRILE DISEASES 
 
 417 
 
 extensive improvements were made in general sanitation, in regard to water, 
 sewage, garbage collection, and general nuisance control, paving, milk inspec¬ 
 tion, federal inspection of meats and the anti-spitting ordinance. While in 
 this analysis it has not been possible to determine any positive beneficial effects 
 upon the tuberculosis mortality-rate to be ascribed to the in many ways pro¬ 
 found and far-reaching modifications of environment, which have included 
 every extreme except those induced by siege and famine, the possibility or 
 even probability of a negative influence may not be denied. For instance, it 
 can not be claimed that, in the absence of the general sanitary reforms and 
 the restrictive and educational measures directed specifically against tubercu¬ 
 losis introduced after 1895, and which reached their climax about 1918, the 
 waves of higher rates which were due and which actually started after 1899 and 
 1912 would not have reached much higher levels than were attained. 
 
 There are rather definite indications which suggest that the course of tuber¬ 
 culosis has been influenced unfavorably by attacks on the community of cer¬ 
 tain acute communicable diseases and affected favorably by the decline in the 
 virulence of some and the practical disappearance of others. 
 
 Whatever the causes of the decline in the mortality from pulmonary tuber¬ 
 culosis may be, they have acted uniformly as to time, though not in the same 
 degree, upon males and females in both the white and colored races. Since 
 about 1880, the curves for both races have followed almost identical courses, 
 though at different levels. In periods of decline, in both races the rates for 
 females have fallen more sharply than those for males. WTiile with the decline 
 in the rates for all ages in each category, the rates for each age-group have 
 dropped, the decrease in mortality has been most conspicuous in the age- 
 groups before the thirtieth year of life. The available data indicate that in 
 regard to color and sex the age distribution of reported cases and deaths has 
 been in close accord. 
 
 These close associations suggest very strongly that the causes which control 
 both incidence and fatality of pulmonary tuberculosis and which act in the 
 same manner though in such different degree in both races and sexes are 
 fundamentally biological. However, this may be, the only positive evidence 
 adduced indicates unmistakably that the rise and fall in the rate for tubercu¬ 
 losis in Baltimore during the 109 years embraced in this study have been 
 determined above all other factors by natural selection, and that in this strug¬ 
 gle between parasite and host under very varied and complex changes of 
 terrain as represented by environment, and of the belligerents themselves as 
 represented by recruits, in the shape of new races as well as by discipline and 
 training, the advantage has been sometimes with the one and sometimes with 
 the other. In these respects tuberculosis has behaved in many, if not in most 
 wavs like several other readily communicable diseases whose courses have been 
 followed in this work. In 1917, on the basis of data presented in this chapter, 
 the writer was forced to the conclusion that the real significance of the various 
 factors concerned in human tuberculosis can not be ascertained with the 
 incomplete and superficial knowledge, relatively inaccurate methods, and the 
 illogical reasoning hitherto so commonly brought to bear upon the question. 
 Nothing short of an exhaustive study of the genetic and environmental history 
 of a very large number of cases promised a solution, and in 1919, at the 
 writer’s suggestion, Professor Raymond Pearl undertook such an investigation 
 of the Baltimore material. 
 
Chapter XII. —Other Acute Febrile Diseases, 
 Some Apparently Contactive. 
 
 Acute meningitis; Poliomyelitis; Tetanus; Erysipelas; Appendicitis. 
 
 (Tables 91 to 100 and 34, 128, 131.) 
 
 ACUTE MENINGITIS. 
 
 In the local statistical nosology, the rubric cerebro-spinal meningitis ap¬ 
 peared in 1872, coincident with an outbreak of the so-called epidemic men¬ 
 ingitis. Three years later* the rubrics meningitis and tuberculous meningitis 
 were added. Before 1872 meningitis of various types was probably classfied 
 for the most part under such indefinite headings as inflammation of the brain, 
 dropsy of the brain, and convulsions, and probably not until 1900 were deaths 
 due to inflammation of the meninges classified with approximate precision 
 under the appropriate rubrics. Of the affections most likely to be confused 
 with acute meningitis, the most prominent are brain tumor, brain abscess, 
 uraemia, and the intoxications of certain acute infectious diseases, such as 
 typhoid fever and pneumonia. The first specific type of acute meningitis 
 to be recognized anatomically and etiologically with certainty was the tuber¬ 
 culous. Though this form has been included in the discussion of tuberculosis, 
 it will be necessary to allude to it here. Of non-tuberculous acute meningitis 
 three types may be recognized: The specific disease due to meningococcus 
 intracellularis meningitidis, the so-called epidemic meningitis, which is not 
 infrequently sporadic also; primary meningitis of other but very diverse etiol¬ 
 ogy, caused for the most part by the pyogenic cocci, but occasionally by other 
 identified micro-organisms and by unknown causes; and secondary meningitis 
 occurring as a complication of wound infection, endocarditis, arterial and 
 venous thrombosis, middle-ear disease, brain abscess, typhoid fever, pneumonia, 
 the eruptive diseases, and injuries of various kinds, particularly of the skull. It 
 is manifest that these types were not differentiated in the statistical classifica¬ 
 tion and that meningitis and cerebro-spinal meningitis must have included 
 the epidemic type, primary and secondary non-tuberculous meningitis of other 
 etiology, and some deaths from tuberculous meningitis. 
 
 It is probable that fewer mistakes were made in the classification of deaths 
 from tuberculous meningitis, and that, on the whole, the figures for this rubric 
 since 1880 reflect actual occurrence with a fair degree of accuracy. It is likely 
 that, particularly in times of epidemic outbreaks, the specific meningococcus 
 meningitis was as a rule classified under the rubric cerebro-spinal meningitis. 
 The rubric meningitis, which has carried the largest proportion of the deaths 
 ascribed to acute inflammation of the meninges, has undoubtedly included 
 many of the deaths from meningococcus meningitis, some deaths due to tubercu¬ 
 losis, and most of those due to primary and secondary meningitis of other 
 causation. The annual mortality from meningitis, as classified under those 
 various headings, with the total mortality from all forms and from men¬ 
 ingitis and cerebro-spinal meningitis combined, is presented in table 91. It 
 
 418 
 
FEBRILE DISEASES 
 
 419 
 
 will be noted that the rates for tuberculous meningitis, beginning with 27 
 in 1875, attained 33, its highest level, in 1877, and fell gradually by somewhat 
 irregular steps to 15 in 1885. After holding about this level during the next 
 4 years and rising to 22 in 1890, it ran an uneven course, with rates varying 
 between 11 and 17, until 1904. With the exception of 1905 and 1911, when 
 the rates were 6 and 15, respectively, the-annual rate varied between 10 and 
 13 until 1919. In the latter year it was 9, and in 1920 it fell to 5. The fluctua¬ 
 tion in the annual rate was not wide and did not synchronize with changes 
 in the rate for the other rubrics. On the whole, the impression is given of 
 an independent disease with rates falling gradually, though somewhat irregu¬ 
 larly, from a peak in 1879 to a relatively low level by 1920. 
 
 While the number of deaths ascribed to cerebro-spinal meningitis fell far 
 short of the whole number that must have been caused by epidemic or men¬ 
 ingococcus meningitis, it is probable that the rates reflect, with some accuracy, 
 the general course of that disease as measured in terms of mortality. It would 
 appear that this affection was present each year between 1872 and 1910, and 
 that upon the endemic basis that followed the epidemic beginning about 1872, 
 the course of the disease lias been marked by several exacerbations, or epi¬ 
 demic outbreaks, the severest of which were those of 1881-1883, 1898-1900, 
 and 1917-1918. Between 1910 and 1912, inclusive, the affection apparently 
 died out. The outbreak of 1917-1918, which fell under the writer’s observa¬ 
 tion, during which all reported cases were investigated bacteriologically, was 
 shown to be due to meningococcus intracellularis meningitidis. 
 
 The rates for the rubric meningitis, supposedly representing chiefly deaths 
 from primary and secondary meningitis of other origin than the tuberculous 
 and the meningococcus forms, are markedly higher than those for these other 
 rubrics. As compared with the other two rubrics, its course manifests a cer¬ 
 tain degree of correlation in that very commonly years in which it registered 
 higher rates synchronized with years of lower rates for one or for both of the 
 others, and years of rising rates for them showed lower or falling rates for it. 
 This picture suggests that, to some degree at least, the fluctuation in the rates 
 for these three rubrics was determined by statistical classification. However, 
 this may be, the rates for meningitis rose from 26 in 1875 to 39 in 1879, and, 
 holding at about the latter level for the next two years, ascended to 47 in 
 1881. Falling by uneven steps during the succeeding 6 years, the rate stood 
 at 34 in 1887, and from this it rose in 1892 to 49, the highest point attained. 
 From this date the trend of the curve is downward. The annual rate was 
 never as high as 40 after 1898, 25 after 1902, nor 20 after 1910. Since 1912 
 the rate has declined steadily to 3 in 1920. 
 
 The sum of the rates for meningitis and cerebro-spinal meningitis may be 
 regarded as in the main representative of the death-rates for non-tuberculous 
 meningitis. If this be true, the tuberculous form has been, during most of the 
 period under consideration, a relatively unimportant cause of death. The 
 curve of the rates for non-tuberculous meningitis, after holding a high level— 
 between 40 and 58 from 1875 to 1901—fell continuously to the low level of 
 6 in 1920. The rate for tuberculous meningitis had by 1900 fallen to 11, 
 which was maintained on an average until 1919, without any significant 
 further fall. 
 
Table 91— Number of deaths and rate of death, per 100,000 living inhabitants, from erysipelas, tetanus and acute diseases of central nervous 
 
 system, from 1812 to 1920, inclusive. 
 
 D = death. R = rate. 
 
 420 
 
 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
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FEBRILE DISEASES 
 
 421 
 
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 system, from 1812 to 1920, inclusive. —Continued. 
 
 422 
 
 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 
 
 
 
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FEBRILE DISEASES 
 
 423 
 
 The sum of the rates for the three rubrics indicates with some degree of 
 accuracy the course of the mortality for the acute infections inflammatory 
 affections of the cerebro-spinal meninges during the 46 years under considera¬ 
 tion. During the first 25 years the course of the curve of mortality varied 
 between 79 and 54. Between 1900 and 1915 the rates fell almost without 
 interruption from 54 to 17. During the next 3 years, owing to a recrudescence 
 of epidemic meningitis, the rate rose to 25, to fall to 18 in 1919 and to 11 
 in 1920. 
 
 When the irregular annual fluctuations in the rates for these three rubrics 
 are smoothed by averaging for 5-year periods (table 92), very much the same 
 
 Table 92.— Average rate of death, -per 100,000 living inhabitants, by 5-year periods, 
 from acute diseases of the central nervous system, from 1812 to 1920, inclusive. 
 
 Periods. 
 
 Meningitis. 
 
 Poliomyelitis. 
 
 Dropsy in the 
 head. 
 
 Inflammation of 
 
 the brain. 
 
 Spinal affections 
 
 and dropsy of 
 
 the spine. 
 
 Total, excluding 
 
 tuberculous 
 
 meningitis. 
 
 Grand total. 
 
 Meningitis. 
 
 Cerebro¬ 
 
 spinal. 
 
 Total. 
 
 Tuberculous. 
 
 All forms. 
 
 1812-15 . 
 
 
 ... 
 
 • • • 
 
 
 
 
 
 
 
 • • • 
 
 • • • 
 
 1816-20 . 
 
 
 • • • 
 
 
 
 
 
 23 
 
 12 
 
 
 35 
 
 35 
 
 1821-25 . 
 
 
 
 
 
 
 
 39 
 
 23 
 
 
 62 
 
 62 
 
 1826-30 . 
 
 
 
 
 
 
 
 33 
 
 19 
 
 
 52 
 
 52 
 
 1831-35 . 
 
 
 
 
 
 
 
 44 
 
 31 
 
 
 74 
 
 74 
 
 1836-40 . 
 
 • 
 
 
 
 
 
 
 35 
 
 24 
 
 
 59 
 
 59 
 
 1841-45 . 
 
 
 
 
 
 
 
 40 
 
 24 
 
 
 64 
 
 64 
 
 1846-50 . 
 
 
 
 ... 
 
 
 
 
 33 
 
 49 
 
 1 
 
 83 
 
 83 
 
 1851-55 . 
 
 
 
 ... 
 
 
 
 
 60 
 
 79 
 
 6 
 
 145 
 
 145 
 
 1856-60 . 
 
 
 
 
 
 
 
 41 
 
 72 
 
 6 
 
 119 
 
 119 
 
 1861-65 . 
 
 
 
 
 
 
 
 26 
 
 63 
 
 5 
 
 94 
 
 94 
 
 1866-70 . 
 
 
 
 • • • 
 
 
 
 
 40 
 
 69 
 
 6 
 
 114 
 
 114 
 
 1871-75 . 
 
 
 18 
 
 18 
 
 5 
 
 23 
 
 
 26 
 
 78 
 
 14 
 
 136 
 
 141 
 
 1876-80 . 
 
 35 
 
 9 
 
 44 
 
 30 
 
 74 
 
 
 14 
 
 14 
 
 1 
 
 73 
 
 103 
 
 1881-85 . 
 
 43 
 
 9 
 
 52 
 
 19 
 
 71 
 
 
 9 
 
 8 
 
 
 68 
 
 87 
 
 1886-90 . 
 
 38 
 
 6 
 
 44 
 
 17 
 
 61 
 
 
 6 
 
 8 
 
 
 57 
 
 74 
 
 1891-95 . 
 
 40 
 
 7 
 
 47 
 
 L5 
 
 62 
 
 
 4 
 
 7 
 
 
 59 
 
 74 
 
 1896-1900 ... 
 
 35 
 
 12 
 
 47 
 
 13 
 
 60 
 
 
 3 
 
 3 
 
 
 54 
 
 67 
 
 1901-05 . 
 
 23 
 
 6 
 
 29 
 
 11 
 
 40 
 
 
 • • • 
 
 1 
 
 
 30 
 
 41 
 
 1906-10 . 
 
 21 
 
 4 
 
 25 
 
 11 
 
 36 
 
 
 • • • 
 
 1 
 
 
 25 
 
 36 
 
 1911-15 . 
 
 13 
 
 1 
 
 14 
 
 12 
 
 26 
 
 
 
 1 
 
 
 15 
 
 27 
 
 1916-20 . 
 
 3 
 
 7 
 
 10 
 
 9 
 
 19 
 
 3 
 
 • • • 
 
 1 
 
 
 14 
 
 23 
 
 picture is obtained. The averaged rate for tuberculous meningitis fell from 
 30 in 1876-1880 to 19 in 1881-1885, to 13 in 1896-1900, and to 11 in 1901- 
 1905. Between 1900 and 1920 it remained almost constant, and the slight 
 drop during the last 5 years is hardly significant. The averaged rate for 
 cerebro-spinal meningitis fell from its high level of 18 in 1871-1875 to 9 in 
 1876-1880, remained unchanged during the next 5 years, and between 1886 
 and 1890 dropped to 6. Ascending to 12, a second high level between 1891 
 and 1900, the averaged rate descended continuously to 1 between 1911 and 
 1915. From 1916 to 1920 the rates averaged 7. The averaged rate for men¬ 
 ingitis, unqualified or so-called simple meningitis, which was 35 for the 
 period ending in 1880, rose to 43 for the next 5 years. Varying but slightly 
 
424 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 from this level from 1886 to 1895 it returned to the initial level of 35 between 
 1896 and 1900. From 1901 to 1920 the rate declined steadily to 3. It will 
 be noted that simple meningitis and cerebro-spinal meningitis fell together 
 between 1901 and 1915, and that between 1916 and 1920 the former con¬ 
 tinued to fall uninterruptedly, while the latter rose. Since 1900, in the statis¬ 
 tical nosology, the latter has represented the meningococcus form and the 
 former acute non-tuberculous meningitis of other etiology. This separation 
 was made with reasonable clearness from 1900 to 1915 and with considerable 
 accuracy between 1916 and 1920. Therefore, the course of the curves for 
 these two rubrics during the past 20 years may be taken to represent the 
 respective lethal importance of these two types of meningitis. The curve of 
 the averaged rates for these two types taken together rose steadily from 18 for 
 
 Table 93 .—Number of cases and monthly annual rate of morbidity, per 100,000 living 
 inhabitants, from epidemic (meningococcus) meningitis, from 1916 to 1920, inclusive. 
 
 C = cases. R = rate. 
 
 
 1916 
 
 1917 
 
 1918 
 
 1919 
 
 1920 
 
 C 
 
 R 
 
 C 
 
 R 
 
 C 
 
 R 
 
 C 
 
 R 
 
 C 
 
 R 
 
 J an. 
 
 1 
 
 2 
 
 • • • 
 
 • • • 
 
 13 
 
 25 
 
 14 
 
 23 
 
 4 
 
 6 
 
 Feb. 
 
 
 
 
 
 23 
 
 49 
 
 14 
 
 25 
 
 4 
 
 7 
 
 Mar. 
 
 
 
 17 
 
 33 
 
 27 
 
 51 
 
 6 
 
 10 
 
 6 
 
 10 
 
 Apr. 
 
 3 
 
 6 
 
 20 
 
 40 
 
 36 
 
 71 
 
 4 
 
 7 
 
 4 
 
 7 
 
 May . 
 
 1 
 
 2 
 
 37 
 
 71 
 
 19 
 
 36 
 
 1 
 
 2 
 
 4 
 
 6 
 
 .Tnrip . 
 
 
 
 23 
 
 46 
 
 8 
 
 16 
 
 4 
 
 7 
 
 4 
 
 7 
 
 July . 
 
 3 
 
 6 
 
 5 
 
 10 
 
 13 
 
 25 
 
 4 
 
 7 
 
 2 
 
 3 
 
 Aug. 
 
 4 
 
 8 
 
 2 
 
 4 
 
 8 
 
 15 
 
 10 
 
 16 
 
 3 
 
 5 
 
 Sppt,. 
 
 
 
 2 
 
 4 
 
 5 
 
 10 
 
 1 
 
 2 
 
 
 
 Oct. 
 
 2 
 
 4 
 
 2 
 
 4 
 
 8 
 
 15 
 
 3 
 
 5 
 
 
 • • • 
 
 Nov. 
 
 
 
 7 
 
 14 
 
 10 
 
 20 
 
 3 
 
 5 
 
 2 
 
 3 
 
 Dec. 
 
 2 
 
 4 
 
 7 
 
 13 
 
 5 
 
 10 
 
 4 
 
 7 
 
 3 
 
 5 
 
 Total . 
 
 16 
 
 3 
 
 122 
 
 20 
 
 175 
 
 28 
 
 68 
 
 9 
 
 36 
 
 5 
 
 Percentage case fatality. 
 
 
 48 
 
 43 
 
 57 
 
 69 
 
 the period ending in 1875 to 52 for the 5 years ending in 1885, deviated but 
 slightly from a level of about 45 to 1900, and descended sharply during the 
 succeeding 20 years. 
 
 The lethal force of all forms of meningitis rose sharply to its peak in the 
 5 years ending in 1885, and, declining gradually during the following 15 
 years, fell conspicuously between 1901 and 1920. During these 20 years acute 
 inflammation of the meninges fell from the position of a principal cause of 
 death to one of comparative insignificance. This decline was due to but small 
 degree to changes in the rate for tuberculous meningitis, which during most 
 of the period held an almost constant level. 
 
 Epidemic or meningococcus meningitis was not reported with any regu¬ 
 larity until 1917. It will be noted (tables 93 and 94) that in 1916 the deaths 
 exceeded the reported cases in number. Since the fall of 1916 special pressure 
 has been brought to bear to secure early and full case reporting, and isolation 
 of cases and contacts has been imposed. Since this time the diagnosis has de- 
 
FEBRILE DISEASES 
 
 425 
 
 pended upon the demonstration of the meningococcus by lumbar puncture dur¬ 
 ing life or at autopsy in fatal cases, and the contacts have been confined or 
 released accordingly as this organism was demonstrated or not in cultures made 
 from the nose and throat. All or nearly all of the cases were treated with anti- 
 meningococcus serum and a large proportion of the cases was hospitalized. 
 For the 4-year period, 1917-1920 inclusive, the data at hand as set forth in 
 table 93 may be regarded as exact. During this period the deaths ascribed 
 to simple meningitis (rubric 61) were proven by the use of bacteriological 
 methods to be due to organisms other than the meningococcus. In this 4-year 
 period no secondary cases of meningococcus meningitis were observed among 
 contacts, either in families or institutions. Several cases in 1917 occurred 
 among a detachment of militiamen, recently recruited, and all from the city. 
 
 Table 94.— Number of deaths and monthly annual rate of mortality, per 100,000 living 
 inhabitants, from epidemic (meningococcus) meningitis, from 1916 to 1920, inclusive. 
 
 D = death. R = rate. 
 
 
 1910 
 
 1917 
 
 1918 
 
 1919 
 
 1920 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 Jan. 
 
 2 
 
 4 
 
 3 
 
 6 
 
 5 
 
 10 
 
 4 
 
 7 
 
 2 
 
 3 
 
 Feb. 
 
 2 
 
 4 
 
 1 
 
 2 
 
 5 
 
 11 
 
 8 
 
 14 
 
 2 
 
 4 
 
 Mar. 
 
 3 
 
 6 
 
 5 
 
 10 
 
 15 
 
 29 
 
 5 
 
 8 
 
 6 
 
 10 
 
 Apr. 
 
 
 
 10 
 
 20 
 
 14 
 
 28 
 
 4 
 
 7 
 
 3 
 
 5 
 
 May . 
 
 1 
 
 2 
 
 13 
 
 25 
 
 11 
 
 21 
 
 2 
 
 3 
 
 1 
 
 2 
 
 June . 
 
 2 
 
 4 
 
 10 
 
 20 
 
 6 
 
 12 
 
 1 
 
 2 
 
 3 
 
 5 
 
 J uly . 
 
 2 
 
 4 
 
 7 
 
 13 
 
 6 
 
 11 
 
 3 
 
 5 
 
 1 
 
 2 
 
 Aug. 
 
 2 
 
 4 
 
 1 
 
 2 
 
 5 
 
 10 
 
 3 
 
 5 
 
 2 
 
 3 
 
 Sept. 
 
 1 
 
 2 
 
 1 
 
 2 
 
 
 
 
 
 2 
 
 3 
 
 Oct. 
 
 
 
 1 
 
 2 
 
 5 
 
 10 
 
 3 
 
 5 
 
 
 
 Nov. 
 
 
 
 3 
 
 6 
 
 1 
 
 2 
 
 4 
 
 7 
 
 2 
 
 3 
 
 Dec. 
 
 3 
 
 6 
 
 3 
 
 6 
 
 2 
 
 4 
 
 2 
 
 3 
 
 1 
 
 2 
 
 Total . 
 
 18 
 
 3 
 
 58 
 
 9 
 
 75 
 
 12 
 
 39 
 
 5 
 
 25 
 
 3 
 
 The sick and their contacts were at once isolated and the disease failed to 
 extend among the command. Whatever advantages may have been gotten by 
 handling this disease with the same method used in diphtheria have been 
 reaped. 
 
 It may be significant that the death-rate was appreciably lower in this out¬ 
 break than in that of 1898-1901. However, the favorable showing was per¬ 
 haps in largest part due to the curative effects of the serum, rather than to 
 isolation methods. The case-fatality rates among the reported cases was 
 48, 43, 57, and 69 per cent for the respective years. In other words, it is 
 probable that the mortality- rather than the morbidity-rates were favorably 
 affected by the introduction of the new methods. The influence of season upon 
 incidence is striking. In the 4-year period 1917-1920, during which the 
 diagnosis of meningococcus meningitis was established with exactness, the 
 peak of both morbidity and mortality (table 94) occurred in later winter 
 months or spring, February, March, April, or May. In these years there was 
 a recrudescence of the disease in the early summer, and in 1919 this was con¬ 
 spicuous. The disease, like the acute exanthematous diseases, dies down during 
 
426 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 the hot months, springs up in the fall, and steadily increases in prevalence 
 during the winter months. The decline from the peak may be gradual or 
 abrupt. In general, the course of the morbidity and mortality curves follow 
 each other closely. 
 
 For the 3 years for which data exist for comparing the influence of color and 
 sex upon mortality (table 95) there were no significant differences for color, 
 in fact, the averaged mortality-rates were the same for both whites and 
 negroes. The mortality-rates were distinctly greater in males than in females 
 of both races, and this difference was much more marked in negroes than 
 in whites. 
 
 The death-rate from tuberculous meningitis had already made its signifi¬ 
 cant decline before the inauguration of the inadequate reforms in the con¬ 
 trol of the milk-supply between 1896 and 1918, and during this period it 
 remained practically unchanged. Nor does it appear that on the average the 
 rate was favorably influenced by the other activities of the department of 
 health exercised through nurses and propaganda, for the death-rate from this 
 
 Table 95. —Number of deaths and rate of mortality, per 100,000 living inhabitants, from 
 epidemic (meningococcus) meningitis, according to color and sex, from 1918 to 
 1920, inclusive. 
 
 D = death. R = rate. 
 
 Year. 
 
 Total. 
 
 White. 
 
 Colored. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 1918 . 
 
 75 
 
 12 
 
 63 
 
 12 
 
 34 
 
 13 
 
 29 
 
 11 
 
 12 
 
 12 
 
 10 
 
 22 
 
 2 
 
 4 
 
 1919 . 
 
 39 
 
 5 
 
 35 
 
 6 
 
 20 
 
 7 
 
 15 
 
 5 
 
 4 
 
 4 
 
 2 
 
 4 
 
 2 
 
 4 
 
 1920 . 
 
 25 
 
 3 
 
 20 
 
 3 
 
 10 
 
 3 
 
 10 
 
 3 
 
 5 
 
 5 
 
 3 
 
 6 
 
 2 
 
 4 
 
 form of tuberculosis was as low between 1900 and 1910 as it was between 1911 
 and 1918. It is quite possible that the considerable decline in the rate which 
 occurred in 1919 and 1920 was due in part at least to the enforcements of 
 proper pasteurization of milk. 
 
 No attempt has ever been made by the health department to erect barriers 
 against the spread of simple meningitis. Restrictive measures were not applied 
 to the spread of epidemic or meningococcus meningitis until 1917, when isola¬ 
 tion of cases and carriers was instituted, and anti-meningococcus serum 
 obtained from the New York City Board of Health was furnished freely for 
 treatment of proven cases. 
 
 It is clear from the foregoing that from 1875 to 1916 the course of acute 
 meningitis was uninfluenced by any artificial interferences instituted by the 
 health department, and that the curve of mortality reflects during this period 
 the natural history of acute inflammatory affections of the cerebro-spinal 
 meninges on the population. For meningococcus meningitis the facts at hand 
 warrant the inference that from 1917 to 1920 the incidence of the disease may 
 have been diminished by restricted measures and the mortality-rates influenced 
 favorably to some degree by the use of anti-serum freely dispensed. 
 
FEBRILE DISEASES 
 
 427 
 
 So much for the picture of the course of meningitis as it may be drawn 
 from the recorded deaths classified under rubrics specifically indicating in¬ 
 flammation of the brain membrane. In regard to repositories for deaths due 
 to inflammation of the meninges before 1872, the statistical nosology con¬ 
 tained, both before and after this date, several rubrics under which such deaths 
 must have been allocated. Of these, the most important are inflammation of 
 the brain, dropsy in the head, hydrocephalus, spinal affection, and dropsy 
 of the spine. To the rubric inflammation of the brain, deaths were ascribed 
 each year (with the exception of 1817 and 1902) from 1816 to 1920. With 
 comparatively slight variation from year to year, the number of deaths cred¬ 
 ited to this rubric increased gradually from 14 in 1818 to 164 in 1853, 221 in 
 1869, 283 in 1871, and 292 in 1872. The number of deaths declined to 241 
 in 1873, to 52 in 1875, and to 31 in 1880. Expressed in relative terms, the 
 rate for this rubric rose from 26 in 1818 to 102 in 1872 and, coincidently 
 with the introduction of the rubrics for meningitis, fell abruptly to 17 in 1875 
 and to 9 in 1880. Between the latter date and 1898, when it stood at 3, the 
 annual rate for inflammation of the brain never rose above 6. As in the 
 light of present knowledge and of the experiences of pathological anatomists, 
 since the middle of the nineteenth century at least, it is inconceivable that 
 the high mortality-rates obtaining for inflammation of the brain before 1875 
 could have represented inflammatory affections of the substance of this organ, 
 the inference is that the greater moiety, if not most, of the deaths ascribed to 
 this rubric were due to meningitis. Between 1816 and 1874, deaths were 
 assigned to dropsy in the head in each year except 1825, 1826, 1846, and 1847. 
 In occasional years the rubric hydrocephalus also occurred. x\£ter 1874, dropsy 
 in the head disappeared and gave place permanently to the rubric hydro¬ 
 cephalus. It is well established that those two terms were used to embrace 
 meningitis of different kinds, that with exudates in both the meninges and 
 the ventricles of the brain, as well as the ordinary congenital hydrocephalus 
 and the various relatively rare types of internal and external hydrocephalus 
 unassociated -with acute inflammation developing after birth. Dropsy in the 
 head and hydrocephalus had attained a death-rate of 49 by 1819, and between 
 this date and 1874 the annual rate varied within wide limits, the highest being 
 90 in 1854 and the lowest 14 in 1863 and 1864. From 58 in 1823, the annual 
 rate had fallen to 18 in 1875 and to 8 in 1882, and since the latter date it has 
 fallen steadily to 2 in 1900, a rate which probably represents the extreme for 
 the congeries of affections now classified under hydrocephalus. There is less 
 certainty in regard to the significance of the rubrics spinal affection and 
 dropsy of the spine, to which there were ascribed a few deaths between 1850 
 and 1870 and as many as 57 and 58 in 1872 and 1873, respectively, and which 
 disappeared after the rubrics for meningitis were firmly established. 
 
 In table 92 are presented the average quinquennial rates from 1816 to 1920 
 for these various rubrics separately and combined. Under the rubrics dropsy 
 in the head and inflammation of the brain, in so far as they may be taken to 
 represent meningitis, some relatively slight deductions must be made from the 
 first for true hydrocephalus in the present use of the term and from the second 
 for the comparatively rare acute inflammation of the brain substance. 
 
 28 
 
428 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 The decline in the rates for dropsy in the head and inflammation of the 
 brain after the introduction of meningitis into the statistical nosology was 
 so marked that the conclusion is forced that previous to 1900 the two former 
 rubrics not only included the latter, but that the combined rates for these 
 rubrics must reflect with some degree of accuracy the course of mortality for 
 meningitis from 1816 to 1900. Viewed in this light, it would appear that during 
 this period meningitis, though subject to several waves of rise and decline in 
 mortality, was continuously a potent cause of death. The period of highest 
 averaged rates was between 1851 and 1880, with the peak (a rate of 145) 
 during the quinquennium 1851-1855. The relatively high rates obtaining up 
 to 1900 were probably due to tuberculous meningitis, meningocoecus men¬ 
 ingitis, and to the prevalence in virulent form of such diseases as measles, 
 scarlet fever, and wound infections, in which the so-called simple meningitis 
 is apt to occur as a secondary complication. Similarly, the considerable fall 
 
 Table 96. —Number of deaths and of reported cases of poliomye¬ 
 litis and rates of mortality and of morbidity, per 100,000 
 living inhabitants, for years 1912 to 1920 and 1915 to 1920, 
 respectively, and the percentage of case fatality for the 
 years 1915 to 1920, inclusive. 
 
 Year. 
 
 Cases. 
 
 Rate. 
 
 Deaths. 
 
 Rate. 
 
 Per cent, 
 case 
 
 fatality. 
 
 1912 . 
 
 • • • 
 
 • • • 
 
 6 
 
 1 
 
 • • • 
 
 1913 . 
 
 • • • 
 
 • • • 
 
 1 
 
 0 
 
 • • • 
 
 1914 . 
 
 • • • 
 
 • • • 
 
 2 
 
 0 
 
 • • • 
 
 1915 . 
 
 26 
 
 4 
 
 4 
 
 1 
 
 15 
 
 1916 . 
 
 206 
 
 34 
 
 70 
 
 12 
 
 34 
 
 1917 . 
 
 2 
 
 0 
 
 0 
 
 0 
 
 0 
 
 1918 . 
 
 38 
 
 6 
 
 5 
 
 1 
 
 13 
 
 1919 . 
 
 83 
 
 12 
 
 28 
 
 4 
 
 34 
 
 1920 . 
 
 15 
 
 2 
 
 4 
 
 1 
 
 27 
 
 Total . 
 
 370 
 
 ... 
 
 120 
 
 • • • 
 
 30 
 
 in the total rate for acute diseases of the nervous system since 1880 may be 
 attributed partly to an active decline in the mortality from tuberculous and 
 meningococcus meningitis, partly to decrease in the virulence of the diseases 
 with which simple meningitis is a complication, and partly to gradual increase 
 in the accuracy of classification of deaths to appropriate rubrics. 
 
 POLIOMYELITIS. 
 
 This disease was first recognized in the statistical nosology in 1912, and 
 since that date it has been credited with one or more deaths in each year except 
 1917. In the latter year 2 cases were reported. It is certain, therefore, that 
 cases of the disease occurred each year during this 9-year period. In table 96 
 are given the data for mortality since 1912 and for morbidity and case fatality 
 since 1915. The number of reported cases does not reflect accurately the true 
 incidence of the disease, for some mild and doubtful cases were certainly over¬ 
 looked. The number of recorded deaths represents actual experience with a 
 fair degree of correctness. The data for the epidemic of 1916 are of unusual 
 
FEBRILE DISEASES 
 
 429 
 
 accuracy, for shortly after the beginning of the outbreak all reported cases 
 were seen by trained diagnosticians, and in all fatal cases careful autopsies, 
 with histological examination of the central nervous system, were made by 
 Dr. Mont Burroughs, of the Pathological Laboratory of the Johns Hopkins 
 University and Hospital, or under his direction. In succeeding years all 
 reported cases have been investigated, and autopsies have been held in fatal 
 cases in which the diagnosis was in doubt. 
 
 A striking characteristic of poliomeylitis has been the regularity of its 
 rise and decline in wave-like fashion. During the 9 years three such waves 
 stand out clearly. The first began abruptly in 1912 and lasted through 1914. 
 The second wave, starting in 1915 with 26 cases and 4 deaths, reached its 
 peak in 1916 with 206 cases and 70 deaths, and subsided in 1917 with 2 
 cases and no deaths. The third wave, much less severe than the second, but 
 
 Table 97 .—Distribution of reported cases and deaths of poliomyelitis, according to 
 
 months, from 1915 to 1920, inclusive. 
 
 C = cases. D = death. 
 
 Month. 
 
 1915 
 
 1916 
 
 1917 
 
 1918 
 
 1919 
 
 1920 
 
 Total. 
 
 C 
 
 D 
 
 C 
 
 D 
 
 C 
 
 D 
 
 C 
 
 D 
 
 C 
 
 D 
 
 C 
 
 D 
 
 O 
 
 D 
 
 Jan. 
 
 
 
 
 
 
 
 
 
 
 
 3 
 
 0 
 
 3 
 
 0 
 
 Feb. 
 
 
 
 
 
 
 
 
 
 
 
 1 
 
 1 
 
 1 
 
 1 
 
 Mar. 
 
 
 
 2 
 
 2 
 
 
 
 1 
 
 1 
 
 
 
 
 
 3 
 
 3 
 
 Apr. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 0 
 
 0 
 
 Mav . 
 
 
 
 
 
 
 
 
 
 1 
 
 1 
 
 
 
 1 
 
 1 
 
 June . 
 
 1 
 
 1 
 
 
 
 
 
 8 
 
 1 
 
 2 
 
 1 
 
 3 
 
 2 
 
 14 
 
 5 
 
 July . 
 
 11 
 
 2 
 
 3 
 
 1 
 
 2 
 
 0 
 
 11 
 
 0 
 
 9 
 
 2 
 
 1 
 
 0 
 
 37 
 
 5 
 
 Aug. 
 
 13 
 
 0 
 
 37 
 
 16 
 
 • • • 
 
 • • • 
 
 7 
 
 2 
 
 27 
 
 10 
 
 2 
 
 0 
 
 86 
 
 28 
 
 Sept. 
 
 1 
 
 1 
 
 71 
 
 24 
 
 • • • 
 
 • • • 
 
 8 
 
 1 
 
 20 
 
 8 
 
 3 
 
 0 
 
 103 
 
 34 
 
 Oct. 
 
 
 
 74 
 
 21 
 
 
 
 3 
 
 0 
 
 16 
 
 5 
 
 1 
 
 1 
 
 94 
 
 27 
 
 Nov. 
 
 
 
 17 
 
 4 
 
 
 
 
 
 7 
 
 1 
 
 1 
 
 o 
 
 25 
 
 5 
 
 Dec . 
 
 
 
 2 
 
 2 
 
 
 
 
 
 1 
 
 0 
 
 
 
 3 
 
 2 
 
 Total . 
 
 26 
 
 4 
 
 206 
 
 70 
 
 2 
 
 0 
 
 38 
 
 5 
 
 83 
 
 28 
 
 15 
 
 4 
 
 370 
 
 111 
 
 more serious than the first, began in 1918 with 38 cases and 5 deaths and 
 attained its peak the following year with 83 cases and 28 deaths. With 15 cases 
 and 4 deaths in 1920, this wave had not reached its ebb. It will be noted that, 
 as a rule, case-fatality rate was highest in the years of greatest incidence. It 
 would appear, therefore, that the invasive and the lethal capacities of the 
 disease have varied together. 
 
 The monthly distribution of reported cases and deaths for 1915 to 1920 
 inclusive is given in table 97. The influence of season upon the incidence of 
 the disease is striking. Cases occurred in January, February, and May in but 
 one year each, and in December and March in only two years. No cases occurred 
 in April. On the other hand, cases were reported in June in 4 of 6 years. But 
 22, or 6 per cent, of a total of 370 cases were reported in the first 5 months of 
 the calendar year. For the remaining months of the year the distribution of 
 reported cases was, in percentages of the total number, July, 10; August, 23; 
 September, 28; October, 25; November, 7; and December, 1. The peak did not 
 
430 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 always fall in September, for in the 3 years of greatest incidence it occurred in 
 July, August, or October. A rise in the number of cases in August over July 
 marked a severer season than usual, but even then, as in 1919, this occurrence did 
 not necessarily presage a continued rise during September and October. Sep¬ 
 tember, then, is the critical month. The occurrence or non-occurrence of cases 
 in the early months of the year is without significance for predicting a heavy 
 or a light visitation in the succeeding months of a particular year. Nor is the 
 occurrence of cases in the early months necessarily associated with the pres¬ 
 ence of recognized cases in the city during November and December of the 
 previous year. 
 
 With the high average fatality among recognized cases, 30 per cent of the 
 total number reported in the 6 years 1915-1920, it is not surprising that the 
 distribution of deaths by months bears a close relation to that of reported 
 
 Table 98 .—Influence of age upon incidence and fatality of poliomyelitis in 1916. 
 
 Age-period. 
 
 Morbidity. 
 
 Mortality 
 
 Percentage of 
 case fatality 
 within age 
 groups. 
 
 Number of 
 cases. 
 
 Percentage of 
 total cases. 
 
 Number of 
 deaths. 
 
 Percentage of 
 total deaths. 
 
 0 to 1 year. 
 
 37 
 
 17.56 
 
 13 
 
 16.17 
 
 35.14 
 
 1 to 2 years.... 
 
 43 
 
 20.98 
 
 16 
 
 23.53 
 
 37.20 
 
 2 to 3 years-... 
 
 53 
 
 25.86 
 
 16 
 
 23.53 
 
 30.19 
 
 3 to 4 years.... 
 
 26 
 
 12.69 
 
 5 
 
 7.35 
 
 19.23 
 
 4 to 5 years.... 
 
 16 
 
 7.80 
 
 5 
 
 7.35 
 
 31.25 
 
 5 to 6 years.... 
 
 9 
 
 4.39 
 
 3 
 
 4.42 
 
 33.33 
 
 6 to 7 years.... 
 
 5 
 
 2.44 
 
 2 
 
 2.94 
 
 40.00 
 
 7 to 8 years.... 
 
 3 
 
 1.46 
 
 3 
 
 4.42 
 
 100.00 
 
 8 to 9 years.... 
 
 3 
 
 1.46 
 
 2 
 
 2.94 
 
 66.66 
 
 9 to 10 years.... 
 
 3 
 
 1.46 
 
 1 
 
 1.47 
 
 33.33 
 
 10 to 15 years.... 
 
 3 
 
 1.46 
 
 2 
 
 2.94 
 
 66.66 
 
 15 to 20 years.... 
 
 3 
 
 1.46 
 
 1 
 
 1.47 
 
 33.33 
 
 20 to 25 years.... 
 
 2 
 
 0.98 
 
 1 
 
 1.47 
 
 50.00 
 
 Total . 
 
 206 
 
 
 70 
 
 
 33.98 
 
 cases. It is worthy of note that the case-fatality rates among the scattered 
 cases of the winter and spring months is higher than among those occurring 
 in the definite outbreaks of the summer and fall months. 
 
 On account of the unusual precautions taken to secure exactness of diag¬ 
 nosis, the data in regard to the influence of age, sex, and race upon morbidity 
 and mortality in the outbreak of 1916 are of special importance. The distri¬ 
 bution of cases and deaths according to the age of those affected is shown in 
 table 98. Over 77 per cent of the cases and 71 per cent of the deaths occurred in 
 children under 4 years of age. Among these, the incidence was greatest in the 
 third year, while the mortality was heaviest in the second year of life. The 
 fourth year of life was marked by lightness of incidence and fatality. In indi¬ 
 viduals over the fifth year of age incidence was light, but fatality was uniformly 
 high. While the case fatality for the whole group was 34 per cent, under the 
 fourth year it was 31.44 per cent, and over this age 42.55 per cent. Both mor¬ 
 bidity and mortality in negroes were double those in whites and somewhat 
 
FEBRILE DISEASES 
 
 431 
 
 greater in males than in females in both races (table 99). The percentage of 
 case-fatality was, however, somewhat lower in negroes than in whites. It was 
 considerably less in females than in males and in white females than in white 
 males. The fatality-rates were identical for the two sexes in negroes. 
 
 Restrictive measures on patients and contacts, with hospitalization of a 
 considerable number of cases, were instituted from first appearance of the 
 diseases in 1916, but there is little evidence of a convincing nature that either 
 these measures or the inadequate quarantine attempted on children from New 
 York and other cities where the disease was prevalent interfered seriously 
 with the spread of the affection. At the very height of the outbreak, the inci¬ 
 dence of the disease dropped abruptly about the middle of October, imme¬ 
 diately after a decided fall in the temperature lasting several days, and 
 subsequent to this, but few cases were reported. 
 
 Table 99. —Rate per 100,000 living inhabitants of morbidity and 
 mortality and percentage of case fatality, according to color 
 and sex, for poliomyelitis for 1916. 
 
 • 
 
 Morbidity. 
 
 Mortality. 
 
 Percent¬ 
 
 age 
 
 case 
 
 fatality. 
 
 Cases. 
 
 Rate. 
 
 Deaths. 
 
 Rate. 
 
 Total . 
 
 206 
 
 34 
 
 70 
 
 12 
 
 34 
 
 Total male . 
 
 107 
 
 36 
 
 39 
 
 13 
 
 36 
 
 Total female .... 
 
 99 
 
 32 
 
 31 
 
 10 
 
 31 
 
 Total white . 
 
 149 
 
 29 
 
 51 
 
 10 
 
 34 
 
 White males .... 
 
 80 
 
 32 
 
 30 
 
 12 
 
 38 
 
 White females ... 
 
 69 
 
 27 
 
 21 
 
 8 
 
 30 
 
 Total colored .... 
 
 57 
 
 59 
 
 19 
 
 20 
 
 33 
 
 Colored males ... 
 
 27 
 
 61 
 
 9 
 
 20 
 
 33 
 
 Colored females .. 
 
 30 
 
 57 
 
 10 
 
 19 
 
 33 
 
 TETANUS AND ERYSIPELAS. 
 
 Tetanus and erysipelas are the only affections associated directly or indi¬ 
 rectly with wound infection that can be traced consistently in the mortality 
 tables from the early years of the nineteenth century. Puerperal fever, which 
 will be considered under child-birth, may be followed as a separate entity 
 only since 1875. Through much of the period a considerable number of 
 deaths have been attributed to abcess of various organs. In the seventies, 
 eighties, and early nineties of the last century a significant proportion of 
 deaths (66 in 1889, for instance) was attributed to peritonitis, many of 
 which were doubtless secondary to appendicitis, puerperal infection, and to 
 operations on the abdominal organs. The numerous deaths that must have 
 been caused by septicaemia, and pyaemia following wound infection were classi¬ 
 fied under other headings. 
 
 Under the heading lockjaw for the most part until 1850, although in some 
 years classed as tetanus, deaths from this disease were recorded in each year, 
 except 1862, from 1812 to 1920 (table 91). From 1875 to 1898, inclusive, a 
 considerable number of deaths were credited annually to trismus nascentium. 
 Since the disappearance of the latter rubric with the adoption of the inter- 
 
432 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 national classification of the causes of death in 1899, deaths from this form 
 of the disease have been classified under tetanus. Previously to 1875, deaths 
 from infantile tetanus were probably classified under convulsions. Judging 
 from the number of deaths attributed to trismus nascentium and to tetanus, 
 respectively (for example, 44 to 11 in 1876; 46 to 16 in 1880; 45 to 12 in 
 1896), infantile tetanus must have been an important cause of death before 
 1875. Before the latter date, therefore, the rates calculated from the official 
 figures for tetanus must be far below actual occurrence. The fluctuations in 
 the rates for tetanus from year to year, both before and after 1875, do not in 
 general vary widely. From table 100, in which the rates for tetanus (includ- 
 
 Table 100 .—Average rate oj death, per 100,000 living inhabitants, by 5-year periods, jor 
 tetanus and erysipelas, from 1812 to 1920, inclusive. 
 
 Periods. 
 
 Tetanus. 
 
 Erysipelas. 
 
 Periods. 
 
 Tetanus. 
 
 Erysipelas. 
 
 Periods. 
 
 Tetanus. 
 
 Erysipelas. 
 
 1812-15 ... 
 
 4 
 
 2 
 
 1851-55 ... 
 
 2 
 
 9 
 
 1891-95 ... 
 
 11 
 
 5 
 
 1816-20 ... 
 
 5 
 
 6 
 
 1856-60 ... 
 
 2 
 
 8 
 
 1896-1900 . 
 
 6 
 
 5 
 
 1821-25 ... 
 
 4 
 
 1 
 
 1861-65 ... 
 
 2 
 
 11 
 
 1901-05 ... 
 
 4 
 
 5 
 
 1826-30 ... 
 
 3 
 
 • • 
 
 1866-70 ... 
 
 3 
 
 7 
 
 1906-10 ... 
 
 4 
 
 4 
 
 1831-35 ... 
 
 4 
 
 2 
 
 1871-75 ... 
 
 7 
 
 14 
 
 1911-15 ... 
 
 3 
 
 4 
 
 1836-40 ... 
 
 2 
 
 1 
 
 1876-80 ... 
 
 16 
 
 9 
 
 1916-20 ... 
 
 1 
 
 4 
 
 1841-45 ... 
 
 2 
 
 2 
 
 1881-85 ... 
 
 16 
 
 10 
 
 
 
 
 1846-50 ... 
 
 3 
 
 11 
 
 1886-90 ... 
 
 13 
 
 8 
 
 
 
 
 ing trismus nascentium) as averaged for quinquennial periods are presented, 
 it will be noted that after rising from 4 for the period 1812-1815 to 5 
 for 1816-1820, the rate fell during the succeeding 10 years, and for the 5 
 years ending in 1830 was only 3. After rising again to 4 in 1831-1835, the 
 rate declined to 2 during the 10 years 1836-1845. Between 1846 and 1870 
 the rate fluctuated between 2 and 3. The appearance of trismus nascentium 
 in statistical nosology was reflected by an abrupt rise in the rates to new high 
 levels—7 in 1871-1875, and 16 in 1876-1885. During the next 15 years the 
 rates sharply declined. During the 10 years 1901-1910, the rates stood at 4, 
 between 1911 and 1915 they fell to 3, and during the last 5-year period to 1. 
 
 While the spectacular rise in the rates for tetanus after 1875 was due to a 
 very marked degree to changes in the custom of classification of deaths, and 
 the rates before this date must be regarded as much too low, the subsequent 
 course of the curve may be taken as indicating with a fair degree of accuracy 
 the force of mortality from tetanus. There can be no doubt that infantile 
 tetanus was of common occurrence during this period. This question was 
 investigated in the late nineties by Dr. C. Hampson Jones, who found the 
 disease especially common in the practice of midwives. In the practice of 
 one midwife he was able to trace 14 deaths from trismus nascentium. There 
 seems little doubt that the marked fall in the mortality-rate from tetanus 
 since 1895 has been due in large measure to improvement in midwifery, the 
 gradual decrease of Fourth of July accidents from fire-crackers and the like, 
 
FEBRILE DISEASES 
 
 433 
 
 the practice of antiseptic and aseptic surgery, and, of late years, the use of 
 prophylactic injections of tetanus antitoxin in connection with wounds suit¬ 
 able for the development of B. tetani. Since 1917 tetanus antitoxin has been 
 furnished free of charge to those unable to purchase it for both prophylactic 
 and curative treatment. 
 
 With the exception of a few years (1819-1821, 1824-1830, 1836-1837, 
 1840-1841, and 1844), erysipelas has been credited with deaths in each year 
 from 1814 to 1920, inclusive. The rates, as averaged for quinquennial periods, 
 are given in table 100. It would appear from the official figures that the disease 
 was either not very prevalent, or at least was characterized by a low mortality 
 until after 1845. The number of deaths rose abruptly from 4 in 1845 to 14 in the 
 following year, and it would appear that at this period there began an epi¬ 
 demic wave that lasted until well after 1890. The rate was no higher during 
 the Civil War period than it was between 1846-1850. T. H. Buckler described 
 as unusual occurrences at the city almshouse and infirmary during the latter 
 period a series of very fatal epidemics of this disease. Rising from 2 for the 
 previous quinquennium to 11 between 1846-1850, the averaged rate for 
 erysipelas varied little from this level until after 1865. Falling during the next 
 5 years to 7, and rebounding to 14 between 1871 and 1875, the rate main¬ 
 tained a level about 9 for 15 years, and held constant at 5 between 1891 and 
 1905 and at 4 from 1906 to 1920. 
 
 Of the various general diseases associated most commonly and most surely 
 with secondary infection with streptococcus, the causal agent of erysipelas, 
 scarlet fever is perhaps the most prominent, and comparison of their course 
 for a possible correlation between their periods of greatest mortality is of some 
 importance. When this is done (tables 34 and 91), it is found that the ascent 
 to high levels in the rate for erysipelas did not begin until 15 years after 
 scarlet fever had attained a high point, that the rate for the latter had fallen 
 from its high level well before that for the former had reached its peak, and 
 that the final decline in the rate for scarlet fever anticipated the fall in the 
 rate for erysipelas. It would appear, therefore, that if comparison of the 
 course of their death-rates indicates anything in this connection, it is that the 
 streptococcus mixed infection in connection with scarlet fever may have been 
 a determining factor in the initial rise in the rate for erysipelas and the subse¬ 
 quent course of that disease. The possible influence of scarlet fever and 
 erysipelas upon the prevalence of puerpural fever will be discussed later. 
 
 Although erysipelas has long been a reportable disease, it may not be claimed 
 that attempts at its control by administrative activity of the health department 
 have materially influenced its course. The admission of known cases to general 
 hospitals for treatment had been debarred by fear of its spread long before the 
 practice was forbidden. Oversight of routine cases in homes has not been prac¬ 
 ticed. Changes in the course of the disease have, then, been due to modifica¬ 
 tion in the infecting agent and its hosts on the one hand and of treatment on 
 the other. 
 
 APPENDICITIS. 
 
 It is only since 1899 that this cause of death can be traced with any accu¬ 
 racy. Previous to this date, with the exception of a few deaths ascribed to 
 typhilitis after 1881 and to appendicitis after 1895, deaths from this cause 
 
434 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 were probably classified chiefly under peritonitis and inflammation of the 
 bowels. The mortality data as annually recorded for typhlitis or appendicitis 
 since 1881 are presented in table 128. It will be observed that from 1890, 
 when interest in this affection appears to have begun, the annual rate rose 
 rather steadily to 10 in 1899. Since this date the annual rate has fluctuated 
 between 10 and 16. But this wide difference in the extremes does not occur 
 as between the first and last years of this period, but rather over short series 
 of years, marking alternate waves of gradual ascent and decline. 
 
 When the rates are averaged for 5-year periods, from 1901 to 1920 (table 
 131) it is found that the average mortality has varied but little, and between 
 the first and the last of these quinquennia there was but a slight increase. It 
 w r ould appear, therefore, that in the mortality from this affection in the period 
 under consideration there is a definite tendency to periodic exacerbations and 
 declines, which, however, are so distributed that over a term of years its lethal 
 force is equalized. As this marks the period in which the diagnosis and surgical 
 treatment and the statistical classification of deaths of this affection have been 
 perfected and stabilized, the recorded mortality-rates may be taken as reflect¬ 
 ing the average annual risk in this population of unpreventable death from 
 tills cause. In other words, since 1901 the risk of the occurrence of appendicitis 
 in degree of severity beyond the sphere of natural resistance and of remedial 
 agencies has been in the ratio of about 12 in 100,000, or 1 in 8,333, for each 
 inhabitant. 
 
PART VI.—VARIOUS CHRONIC ORGANIC DISEASES. 
 
 Chapter XIII. —Tumors. 
 
 (Tables 101 to 109, graphs 27 to 29.) 
 
 With the exception of 1815 and 1823, deaths from cancer have been recorded 
 every year since 1813, but not until 1875 were they classified by organs af¬ 
 fected. In that year deaths from this affection were classified under cancer— 
 diffused, breast, liver, face, rectum, uterus, stomach, neck, leg, brain, and 
 pylorus. In 1878 there were added, cancer of the tongue, testicle, intestines, 
 oesophagus, trachea, mouth, eye, mesentery, arm, omentum, elbow, and spine. 
 Between this date and the adoption of the international system of classification 
 in 1899, the statistical rubrics were expanded to include each organ or part 
 certified in any particular year as the seat of fatal cancer. Since 1905, these 
 have been contracted to conform to the limits of the international system. 
 
 Though the rubric tumor appeared in the statistical records in 1821, 1822, 
 1829, and 1830, it was not until 1833 that it became permanently established. 
 Not until 1875 were the deaths classified by organs affected, i. e., ovary, abdo¬ 
 men, uterus, rectum, and face. As with cancer, the statistical nosology was 
 expanded to include such other organs, but usually only the brain, to which 
 deaths from tumors were ascribed. 
 
 That not all deaths due to cancer were properly assigned in the earlier 
 years is clear from the fact that in 1878, to cite one example, there were 
 ascribed to stricture of the rectum 1 death, of the cardiac end of the stomach 
 6 deaths, and of the intestine 3 deaths. In 1875, 1 death was attributed to 
 tumor of the rectum and another to tumor of the face—very unlikely seats 
 for fatal benign tumors. Since 1910, under the classification rules of the 
 Bureau of the Census, tumor of the brain, which from this date has been 
 recognized with greater frequency than before through the development of 
 operative procedures for its relief, has been hidden under “ other diseases of 
 the nervous system.” Because a considerable proportion of brain tumors are 
 malignant, this practice has affected the rates for both cancer and tumor. 
 After 1899, deaths ascribed to tumor, with a few relatively unimportant 
 exceptions, have been those thought to have been due to benign tumors of the 
 female generative organs—the ovary and the uterus. Therefore, before this 
 date and particularly in the earlier years, no sharp distinction was drawn 
 between cancer and tumor, and the latter rubric by no means always meant 
 benign tumor, as opposed to cancer. It is likely, however, that the old rubric, 
 cancer, included most tumors now classified under the general heading of 
 cancer and other malignant tumors. 
 
 It would serve no useful purpose to trace here the history of the various 
 conceptions of tumors and their classification. It will suffice to point out that, 
 before the beginning of the period under review, it was established that tumors 
 are non-infiammatory or autochthonous new growths, and that benign tumors 
 
 435 
 
436 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 cause death mainly by mechanical pressure resulting from position and size, 
 and by such accidents as hemorrhage and torsion, while cancerous or malig¬ 
 nant growths tend to spread locally and distantly and, in some ways even yet 
 unknown, to exert, as a rule, specific deleterious effects upon the body as a 
 whole, resulting in anaemia, prostration, and finally death. 
 
 In table 101 the data for cancer and tumor are presented separately and 
 combined. It will be noted (graph 27) that the crude mortality-rates for 
 tumors as a whole were relatively low until after 1870. With considerable 
 fluctuations, the annual rates ascended from 2 in 1813 to 15 in 1821 and to 
 20 in 1846. By 1850 the rate had fallen to 9, and it was not until 1865 that 
 the level of 1846 was again attained. After rising to 27 in 1868 and falling 
 to 20 by 1870, the rate rose steadily, with but few recessions, to 117 in 1920. 
 Through most of the period between 1835 and 1920, the rates for tumor alone 
 show considerable annual fluctuations. Always inconsiderable, the rates ex¬ 
 ceeded 10 in but one year. These rates rose decidedly between 1865 and 1877, 
 and between the latter year and 1905 there was on the whole but little change. 
 The rates fell appreciably between 1906 and 1915, but from 1916 to 1920 they 
 approached their former higher level. 
 
 During the entire period under review, the curve of the rates for cancer alone 
 has followed closely that of the combined rate, and the predominant impor¬ 
 tance of this rubric has determined the shape of the curve for the combined 
 rate. The rates for cancer, with considerable fluctuations, varied from 2 in 
 1813 to 11 in 1835. After fluctuating between 5 and 15 from 1835 to 1865, 
 the annual rate reached 20 for the first time in 1867. Having reached 51 in 
 1880, after several advances and declines, the rate rose, with relatively minor 
 recessions, to 113 in 1920. 
 
 When the irregularities due to minor annual fluctuations are smoothed by 
 averaging the rates for 5-year periods (table 102 and graph 28), a sharply 
 cut picture of the course of mortality of these affections is presented. The total 
 rate rose from 4 for the period 1812 to 1815 to 8 for the 5-year period end¬ 
 ing in 1820. Following a slight recession during the next 5 years, the rates 
 rose to 9 between 1826 and 1830, and fell to 8 for the period ending in 1835. 
 The rates remained practically stationary at 11 between 1836 and 1845 and 
 at 13 between 1846 and 1860. The slight increase to 16 for the succeeding 5 
 years was followed by a sharp rise to 23 for the period between 1866 and 1870. 
 From this date, but for a slight recession for the 5 years 1881-1885, the rates 
 rose steadily between 1866 and 1920, and reached 111 for the period 1916- 
 1920. The averaged rates for tumor which never attained 4 before the 5-year 
 period ending in 1870, gradually rose during the next 10 years and averaged 
 7 between 1876 and 1880. This gain was more than lost during the next 5 
 years, but after 1885 the course of the rates turned and rose steadily to 8 for 
 the 5 years ending in 1905. Falling during the next 10 years to the level of 
 1870, for the period between 1911 and 1915, the average rate for the 5 years 
 ending in 1920 was 5. For cancer, the averaged rates were 4 between 1812 
 and 1815, and 8 during the next 5 years. After receding to 4 between 1821 
 and 1825, and rising to 9 between 1826 and 1830, the rates remained prac¬ 
 tically stationary between 1831 and 1850. Rising but slightly to 11 between 
 1851 and 1860 they ascended more rapidly during the next 15 years to 26 
 for the period ending in 1875. Between 1876 and 1885 the rates averaged 
 
VARIOUS CHRONIC ORGANIC DISEASES 
 
 437 
 
 47, and from 1886 to 1920 the rates rose to 106. It will be noted that after 
 1895 the rate increased by from 7 to 10 for each 5-year period. 
 
 Data are available for calculating the effect of color and sex upon the crude 
 rates for cancer for the 21-year period 1900-1920. These are set forth in 
 table 103. In this period the rates for whites rose from 64 to 116 and for 
 negroes from 55 to 95. For sex, the increases in the rates were: White, males 
 from 46 to 108, females from 81 to 124; negro, males from 23 to 69, females 
 from 81 to 119. The course of the rates for both sexes in whites was much 
 smoother than in negroes. The annual fluctuations in the rates for negro 
 males were particularly marked. There were on the whole no great differences 
 between the rates for females of the two races. In few years, however, do the 
 rates for negro males approach those for white males. In no one of the four 
 groups did the rates fail to increase considerably during the period. 
 
 The influence of age upon death-rates for cancer in 1911 and 1920 is shown 
 in table 104. The whole of the mortality below the thirtieth year of life 
 occurred in the white race, in which the rate below the tenth year was 2, 
 between the tenth and nineteenth years only 3, and between the twentieth 
 and twenty-ninth years only 25. Under the tenth year nearly all the deaths 
 occurred in the first year of life, when the rate was 11. The high fatality during 
 the first year of life was doubtless due to congenital tumors, for the most part 
 teratoid. The malignant tumors fatal for the ages 10 to 30 were probably 
 for the most part sarcomata. Following the rates for the whole population 
 from the thirtieth year, it will be noted that they rose from 12 for the third 
 decade to 28 for the fourth, to 114 for the fifth, to 299 for the sixth, to 464 
 for the seventh, to 603 for the eighth, and to 1,123 for 80 years and over. 
 The rates for the white population were nearly double those for the negro in 
 the third decade, but after this period they conformed closely to those for 
 the whole population during the remainder of the life-span. The rate for the 
 negro, which somewhat exceeded the white and the total rates in the fifth 
 decade, fell somewhat below those in the sixth and seventh decades, and drop¬ 
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 to 676 for 80 years and over. From birth to the fortieth year and from the 
 sixtieth year to the end of life, therefore, the rates for whites were decidedly 
 higher than those for negroes. 
 
 In comparing the two sexes, all the deaths during the first year were in 
 white females, and all those between the first and the ninth year were in 
 white males. The rates for whites of both sexes under the tenth year were 
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 rising to the level of the rates for white females for the fourth decade, the 
 rate for negro females was 226 in the fifth decade. Again approaching the 
 rate for female whites in the sixth and seventh decades, the negro female 
 rates fell decidedly from 574 in the seventh to 337 in the eighth decade. For 
 
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 Percentage 
 
 of total 
 
 deaths 
 
 from 
 
 all causes- 
 
 cococ^eocoeoTtiTti^rt<coTtiT*iTfiioio*o^iooioio*oco<c>o<ocDT^r^oo 
 
 • 
 
 Total. 
 
 PS 
 
 r-ifH«)(NtHO}tHO^(0!»OOOOailN©OOCDC300©NlO«NH®tHOON 
 
 f-!OIO®©ffitHt't'tH®NNNOa)QOOOOOCJ050SOCCHOOOH 
 
 rH rH rH rH r-H rH rH rH 
 
 Q 
 
 NNC3(N(NmO>(N©oO«0«)CROrtOCO^(NOi^NO'#lO^COCIONO 
 
 OaiOMHMCO^OfH'^OOHOOOQOJOONlOWCCWHTKtHOlOtHCO 
 
 W(N(NM««ncOCO««^'^^'^'^V<^-^rtU(3»0‘OCDCDCOCOCOCOtHOO 
 
 Tumor. 
 
 PS 
 
 r^tH.cotH.coTjiooutir^ooU3oo»r303t^ootH'^coTt<io»r3'^'^cococoiocO'^ir5 
 
 Q 
 
 HOffiHOHNffilOoi'ON^aOiHOMlOlNOOOlNNOlOOOOOOHOOCO 
 
 WCONNNINCCKNCOnM'^W'^'^'^'^INWlNMNCSNHrHCOMMWW 
 
 Cancer, 
 
 PS 
 
 ■<HONU3INT)(C5lOfHooMO^O'fH(NWO©(NHnHOTtUOlOCOMlM 
 
 ®©lQlOffl©ffi®©o©tHMHOOOOOOMOOtHOaaiOOOOOOOH 
 
 rH l-H l-H i-H r-H rH rH rH 
 
 a 
 
 fflNCOHONNOHoiOOOO'l'OONOnOOOOWOOlfJNfflONON 
 
 fHCCOlOCOOCOiHCOMHlOOOtHlOCOlON^lOIMIN^CJCRlNMTttW^IN 
 
 <N<N<M03C^CCOOOOCOcoWC'OOOC<0''*''*l'<*'«4<-'tf-<*U01CO»COlCOlCDCOCOCOCOt'rOO 
 
 Cardio-vascular renal diseases. 
 
 Percentage 
 
 of 
 
 total deaths 
 from 
 
 all causes. 
 
 N(NNinCO®lQ®10rHNrH03000HHNlNWlCi[HNNO>05Hf0030 
 
 hhhhhhhhhhHhhmMNNNNNNMNNNMNCONNM 
 
 Total. 
 
 cs 
 
 ^«(N®N100«HoO^WC3iJlT»(OM<HTjH^©tHNNWHTjtNlHHN 
 
 NOO©0®^(NHIN^lOlO©COHOH«HO®THNlOtHK)H©05ffl»0 
 
 NNNCOWCOCOCOMcoCOCOCOCO^^TjHiHTjiTH^if^-tTiHTltlOlOIO^iH 
 
 a 
 
 ©M^CONNNMCOHlOCOHlOOlNNHOO^^NffiHWJNNlOfflO 
 
 OOlOHC3HNMNOOTl<ffiHNINH®©CCl(NCO®OOOOC5(NCJHtHCC(NW3 
 
 H^«coNffiioinioiHtHooc»o(NHiNn«(N®iON®co!)OTHTji®con 
 
 HHHrtHHHHHHHHHNNINNNNMNlN(NIN(N<NCOnWnCO 
 
 Dropsy. 
 
 PS 
 
 COOJ10N®OONCOlO^«NfOM«NHHNH. 
 
 a 
 
 00«(NlNN®lOWO©f'O^MNOtH'<JiaCH. 
 
 N«NCCNCC«HINHHrtHHHH . 
 
 Nephri¬ 
 
 tis. 
 
 PS 
 
 OlOOCSN0inaN'^C5®n(M'<J<00®ffiQ^lC05H®®®tH'^©0!>0) 
 NtHCJC5U3HHHHMeJMK'ltlO>0®®®®a)®C5tHlO®®OOOOIO'^ 
 rH rH rH rH rH rH rH rH rH rH rH rH rH rH rH rH rH rH rH rH rH rH rH rH r-H rH 
 
 Q 
 
 'MHOOfflOlHCOOOOOlOH^MacOIOrofflOrflOOOOOMfflCONH 
 
 OW01C®IOiJtTttU3®10lOC!»OINU30W^(N10NH'iHlN©HIM'^COO) 
 
 COW^'HWlOIOlOlOCOOCONOOOOCJOJOOOOHOOiroOHHHO 
 
 rH rH r-H rH rH rH rH rH 
 
 Aneurism 
 
 and 
 
 arterio¬ 
 
 sclerosis. 
 
 PS 
 
 MNW(N(NCON'!tt®N^ai(NN®(NH©H(»H®nH(N®OCONO® 
 
 HHH(MiM(M(M(NH(MM«CClMICOlON«n(NMH 
 
 Q 
 
 !OH«OOCOOOHCOH©(N'#'#NMNN(»©t'^(NHffiOnffl^W3 
 rH rH rH rH rH rH rH CSI CO CO t-“ 03 rH rH ICO rH r-H O rH ICO t*-* O ICO CO rH ICO 00 O CO ^ rH 
 
 hhhhhhhhhinnhcchhcihhh 
 
 Diseases of cerebral blood 
 vessels. 
 
 Total. 
 
 PS 
 
 (NffilOlOOCOCOOOOOHIN^^OTjUOHNOOINOHOOOHlOOM 
 
 OONNOOOOQNNt't'OOOONNNCOONOlONNt^OlOOOHlNCOHH 
 
 rH rH rH rH rH rH 
 
 a 
 
 ©C3»COC003l>-OOOOTtlC3i-HCOT*rHlCOt^r'-.COCOC©<MCOt^OO»C3lC01>.03lCOOOeO 
 
 ico^eooo©mT)(©NcorH(Nooo30Hf>oaNHOHowrHicooconcoN 
 
 coeocococo-^cocococO'^H^coco , ^cococoeocoT^H^rt<icoio©rriD-oooooo 
 
 Softening 
 
 of 
 
 the brain. 
 
 PS 
 
 OCOOOOOCOOIOIO •COOOCOX^'^IO^COIN^WCOHHHHH • H H • 
 t—H • • • 
 
 Q 
 
 (NOO^OONMOIO -1—l(NC3©<MTfia3©»rOCOrHC<»OOt^OOCOlCOl003COHtieO 
 
 •^NCOCONTj<M(M -COiJKN^NNINNHHINHH 
 
 Apoplexy. 
 
 PS 
 
 MMNN^rJ1Nr-i©(NWN©OHaia00i0(NC00300OIC3C0©OiH©C; 
 
 NN©t-000©Nr-I>t^N®NN»0©©©lO©©©03000H(NmHH 
 
 rH rH rH rH rH rH 
 
 O 
 
 OOHHO(NlfO(NM^OOO>^^aiH(»NMn©OCOOOCJO(NN®^0 
 
 OWOlO^ffilN^t^lOOOTjiOOOHCONOOaiOOCOOlOOOOINMlM 
 
 COCOCOCOCOCOCOCOCOCOCOCOCOCOCOCOCOCOCO(NCOCOHjHlCO»C3COt'-.t^OOOOOO 
 
 Diseases of the heart. 
 
 Total. 
 
 PS 
 
 CO © © CO t— CO UO CO 03 CO © CO CO hji CO ^ rH rH CO ICO © © CO 03 03 © rH 03 00 t>» © 
 rHiHMHHCINHC)HOC)C0'^10©©©10»O00NN©r'00©(N^©00 
 rHrHrHrHi-HrHr-HrHr-HrHrHr-HrHrHrHi-Hr-Hi—IHHHHHHHHNNNHH 
 
 Q 
 
 COTHOOOO»COC300lCO<D303©Htf©t^lO»COrHTt<CO©©ICOlM©t^COt^r-HCOt^rH 
 OJOCOHrJiOOOI^OCOiJfCOr-iWiHCOCOONNCOCOHCOOCOHOCOOlN 
 rfl ICO ICO ICO ICO ICO ICO ICO © ICO © © I"- 00 CO 00 0000000030©©Od^©NCO 
 
 r-H rH rH rH rH r-H rH rH r-H 
 
 Organic 
 
 diseases 
 
 of 
 
 the heart. 
 
 Ph 
 
 ©rH©OOMNNnC'©H©H©^NCO^OONHON©OCOOOO©a>0 
 
 OHHOHHHHHH(NHC , 3CO'^'^lOlCOTHr*INOfflTj(©l>©HCO>C5N 
 
 rH rH r-H rH i—IrHr-HrHi —1 i—1 i—Ir-HrHrHrHrHr-HrHrHrHrHrHrHr-HrHrHrHCSOIrHr-H 
 
 Q 
 
 W(N©-#©(NH0000NmN«NH^aiMffiTt(00NTj(N©00Hffl(N©O 
 ©C3H03(NW©^NlOiHOOOiHN©CO©(NCOC^(N'^f^OCOlCOCO»OT)110 
 •<tlTj<lC0TtllC0lC0lC0»C0lC0lC0©lC0©t-rr— t-r00 00 00 00 03 C3C300©OrHC0TtfrH03 
 
 i-H r-H r-H rH rH rH rH 
 
 Angina 
 
 pectoris. 
 
 PS 
 
 NNIOIO^(OOOCOIOO^NOOOOOXOOOOOOJ>C50(NOONhHCOOO 
 
 r-H r-H r-H rH r-H rH r-H rH 
 
 a 
 
 i-HCSC0r^©©l^.l^Tji©r^r^C0©TtirH(N<N'^O3(M00 00©O3lO©lC0rH(MrH 
 COCOCS<N<MCOCOC'303CO(MCOCO'<i<TH'r*l'>^T*lTHTtllc01CO©lCO©'^©©00©t>- 
 
 Year. 
 
 ©!-HlMCO'^lO©r^OO©©rH(D3CO-<tl»CO©I^OO©©rH(NCO'^lOCOrrOO©© 
 ©03©03©G3C3©©©©©©©00©©©©rHrHrHrHrHrHrHi—1 H H W 
 oDMCoooooooKooooooaocsoojOffloocaoaffloffioiooooios 
 
 rH r-H rH rH rH r-H rH rH r— 1 rH rH rH r-H rH rH rH rH rH rH rH rH rH rH rH rH rH rH rH rH rH rH 
 
 (440) 
 
VARIOUS CHRONIC ORGANIC DISEASES 
 
 441 
 
 Graph 27 (from table 101). Annual crude mortality rates from tumor 
 (cancer and other tumors) and from cardio-vascular-renal diseases, from 
 1812 to 1920, inclusive. 
 
 Table 102.— Average rate of death, per 100,000 Hiring inhabitants by 5-year periods, 
 from cancer, and other tumors, and from senility and causes unknown in adults, 
 from 1812 to 1920, inclusive. 
 
 Periods. 
 
 Cancer. 
 
 Tumor. 
 
 Total 
 
 cancer and 
 tumor. 
 
 Senility. 
 
 Causes 
 
 unknown. 
 
 Total 
 senility 
 and causes 
 unknown. 
 
 1812-15 . 
 
 4 
 
 • • • 
 
 4 
 
 145 
 
 • • • 
 
 145 
 
 1816-20 . 
 
 8 
 
 • • • 
 
 8 
 
 123 
 
 • • • 
 
 123 
 
 1821-25 . 
 
 4 
 
 1 
 
 5 
 
 120 
 
 39 
 
 159 
 
 1826-30 . 
 
 9 
 
 • • • 
 
 9 
 
 119 
 
 56 
 
 175 
 
 1831-35 . 
 
 7 
 
 1 
 
 8 
 
 126 
 
 30 
 
 156 
 
 1836-40 . 
 
 8 
 
 2 
 
 10 
 
 95 
 
 22 
 
 117 
 
 1841-45 . 
 
 9 
 
 3 
 
 12 
 
 76 
 
 40 
 
 116 
 
 1846-50 . 
 
 10 
 
 3 
 
 13 
 
 96 
 
 74 
 
 170 
 
 1851-55 . 
 
 11 
 
 2 
 
 13 
 
 100 
 
 56 
 
 156 
 
 1856-60 . 
 
 11 
 
 3 
 
 14 
 
 94 
 
 73 
 
 167 
 
 1861-65 . 
 
 14 
 
 2 
 
 16 
 
 85 
 
 63 
 
 148 
 
 1866-70 . 
 
 19 
 
 4 
 
 23 
 
 89 
 
 62 
 
 151 
 
 1871-75 . 
 
 26 
 
 6 
 
 32 
 
 100 
 
 36 
 
 136 
 
 1876-80 . 
 
 47 
 
 7 
 
 54 
 
 72 
 
 4 
 
 76 
 
 1881-85 . 
 
 47 
 
 4 
 
 51 
 
 77 
 
 3 
 
 80 
 
 1886-90 . 
 
 57 
 
 6 
 
 63 
 
 74 
 
 1 
 
 75 
 
 1891-95 . 
 
 59 
 
 6 
 
 65 
 
 80 
 
 
 80 
 
 1896-1900 . 
 
 66 
 
 7 
 
 73 
 
 65 
 
 
 65 
 
 1901-05 . 
 
 76 
 
 8 
 
 84 
 
 54 
 
 
 54 
 
 1906-10 . 
 
 84 
 
 5 
 
 89 
 
 41 
 
 
 41 
 
 1911-15 . 
 
 97 
 
 4 
 
 102 
 
 28 
 
 
 28 
 
 1916-20 . 
 
 106 
 
 5 
 
 111 
 
 12 
 
 
 12 
 
442 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 Graph 28 (from tables 102 and 110). Crude mortality rates from tumors 
 (cancer and other tumors), cardio-vascular-renal diseases, and senility and 
 causes unknown in adults, averaged by five-year periods, from 1812 to 1920, 
 inclusive. 
 
 Table 103. —Number of deaths and the rate of death, per 100,000 living inhabitants, from 
 cancer, according to color and sex, from 1900 to 1920, inclusive. 
 
 D = death. R = rate. 
 
 Year. 
 
 Total. 
 
 White. 
 
 Colored. 
 
 Total* 
 
 Male. 
 
 Fem. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 D 
 
 R 
 
 D 
 
 R i 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 1900 . 
 
 318 
 
 63 
 
 275 
 
 64 
 
 95 
 
 46 
 
 180 
 
 81 
 
 43 
 
 55 
 
 8 
 
 23 
 
 35 
 
 81 
 
 1901 . 
 
 358 
 
 70 
 
 319 
 
 73 
 
 118 
 
 56 
 
 201 
 
 90 
 
 39 
 
 49 
 
 7 
 
 20 
 
 32 
 
 73 
 
 1902 . 
 
 384 
 
 74 
 
 340 
 
 77 
 
 128 
 
 60 
 
 212 
 
 93 
 
 44 
 
 55 
 
 13 
 
 36 
 
 31 
 
 70 
 
 1903 . 
 
 370 
 
 70 
 
 332 
 
 74 
 
 121 
 
 56 
 
 211 
 
 92 
 
 38 
 
 47 
 
 12 
 
 33 
 
 26 
 
 58 
 
 1904 . 
 
 450 
 
 84 
 
 391 
 
 87 
 
 147 
 
 67 
 
 244 
 
 105 
 
 59 
 
 71 
 
 18 
 
 49 
 
 41 
 
 90 
 
 1905 . 
 
 437 
 
 81 
 
 380 
 
 83 
 
 152 
 
 68 
 
 228 
 
 97 
 
 57 
 
 68 
 
 17 
 
 45 
 
 40 
 
 87 
 
 1906 . 
 
 450 
 
 82 
 
 390 
 
 84 
 
 146 
 
 65 
 
 244 
 
 103 
 
 60 
 
 71 
 
 24 
 
 63 
 
 36 
 
 77 
 
 1907 . 
 
 473 
 
 85 
 
 415 
 
 89 
 
 168 
 
 74 
 
 247 
 
 103 
 
 58 
 
 67 
 
 13 
 
 33 
 
 45 
 
 95 
 
 1908 . 
 
 449 
 
 80 
 
 386 
 
 82 
 
 148 
 
 64 
 
 238 
 
 99 
 
 63 
 
 72 
 
 17 
 
 43 
 
 46 
 
 96 
 
 1909 . 
 
 450 
 
 79 
 
 393 
 
 82 
 
 142 
 
 61 
 
 251 
 
 103 
 
 57 
 
 64 
 
 19 
 
 47 
 
 38 
 
 78 
 
 1910 . 
 
 529 
 
 92 
 
 474 
 
 98 
 
 176 
 
 74 
 
 298 
 
 121 
 
 55 
 
 61 
 
 12 
 
 30 
 
 43 
 
 88 
 
 1911 . 
 
 526 
 
 91 
 
 469 
 
 96 
 
 195 
 
 82 
 
 274 
 
 110 
 
 57 
 
 63 
 
 15 
 
 36 
 
 42 
 
 85 
 
 1912 . 
 
 545 
 
 93 
 
 480 
 
 98 
 
 177 
 
 73 
 
 303 
 
 121 
 
 65 
 
 71 
 
 19 
 
 45 
 
 46 
 
 92 
 
 1913 . 
 
 598 
 
 101 
 
 510 
 
 103 
 
 198 
 
 81 
 
 312 
 
 124 
 
 88 
 
 94 
 
 33 
 
 78 
 
 55 
 
 108 
 
 1914 . 
 
 595 
 
 100 
 
 515 
 
 '103 
 
 205 
 
 83 
 
 310 
 
 122 
 
 80 
 
 85 
 
 20 
 
 47 
 
 60 
 
 117 
 
 1915 . 
 
 627 
 
 104 
 
 564 
 
 111 
 
 235 
 
 94 
 
 329 
 
 128 
 
 63 
 
 66 
 
 28 
 
 64 
 
 35 
 
 67 
 
 1916 . 
 
 636 
 
 105 
 
 550 
 
 108 
 
 261 
 
 104 
 
 290 
 
 112 
 
 85 
 
 88 
 
 25 
 
 57 
 
 60 
 
 114 
 
 1917 . 
 
 640 
 
 105 
 
 568 
 
 110 
 
 255 
 
 100 
 
 313 
 
 120 
 
 72 
 
 74 
 
 23 
 
 51 
 
 49 
 
 92 
 
 1918 . 
 
 637 
 
 103 
 
 564 
 
 109 
 
 234 
 
 91 
 
 330 
 
 126 
 
 73 
 
 74 
 
 29 
 
 64 
 
 44 
 
 82 
 
 1919 . 
 
 749 
 
 104 
 
 660 
 
 107 
 
 286 
 
 93 
 
 374 
 
 121 
 
 89 
 
 85 
 
 27 
 
 56 
 
 62 
 
 110 
 
 1920 . 
 
 827 
 
 113 
 
 724 
 
 116 
 
 332 
 
 108 
 
 392 
 
 124 
 
 103 
 
 95 
 
 37 
 
 69 
 
 66 
 
 119 
 
VARIOUS CHRONIC ORGANIC DISEASES 
 
 443 
 
 80 years and over it rose, however, to 985, as compared with 1,252 for white 
 females. For 1920, the rates followed somewhat different courses. In conse¬ 
 quence of the considerable mortality in the first decade and the absence of 
 mortality in the second decade among negroes, the rates for this race and for 
 the total population were higher in the first than in the second 10 years of 
 
 Table 104 .—Number of deaths and rate of death, per 100,000 living inhabitants, from 
 cancer, according to age, color, and sex, for 1911 and 1920 * 
 
 D = death. R = rate. 
 
 Age-period. 
 
 Total. 
 
 White. 
 
 Colored- 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 I) 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 1911 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Under 1 year.... 
 
 1 
 
 10 
 
 1 
 
 11 
 
 • • • 
 
 • • • • 
 
 1 
 
 23 
 
 
 
 
 
 
 
 Betw. 1 and 2 yrs. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 2 to 4 years.... 
 
 1 
 
 3 
 
 1 
 
 4 
 
 1 
 
 7 
 
 
 
 
 
 
 
 
 
 5 to 9 years... . 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 0 to 9 years.... 
 
 2 
 
 2 
 
 2 
 
 2 
 
 1 
 
 2 
 
 1 
 
 o 
 
 * 
 
 
 
 
 
 
 
 10 to 19 years.... 
 
 3 
 
 3 
 
 3 
 
 3 
 
 2 
 
 5 
 
 1 
 
 2 
 
 
 
 
 
 
 
 20 to 29 years.... 
 
 14 
 
 12 
 
 11 
 
 25 
 
 5 
 
 11 
 
 6 
 
 13 
 
 3 
 
 15 
 
 1 
 
 11 
 
 2 
 
 17 
 
 30 to 39 years.... 
 
 25 
 
 28 
 
 21 
 
 29 
 
 7 
 
 20 
 
 14 
 
 37 
 
 4 
 
 25 
 
 1 
 
 13 
 
 3 
 
 37 
 
 40 to 49 years.... 
 
 78 
 
 114 
 
 61 
 
 107 
 
 20 
 
 73 
 
 41 
 
 138 
 
 17 
 
 149 
 
 4 
 
 71 
 
 13 
 
 226 
 
 50 to 59 years.... 
 
 135 
 
 299 
 
 119 
 
 305 
 
 49 
 
 259 
 
 70 
 
 347 
 
 16 
 
 264 
 
 6 
 
 203 
 
 10 
 
 322 
 
 60 to 69 years.... 
 
 115 
 
 464 
 
 104 
 
 475 
 
 40 
 
 405 
 
 64 
 
 532 
 
 11 
 
 381 
 
 2 
 
 152 
 
 9 
 
 574 
 
 70 to 79 years.... 
 
 63 
 
 603 
 
 61 
 
 645 
 
 26 
 
 660 
 
 35 
 
 634 
 
 2 
 
 201 
 
 • • • 
 
 • • • 
 
 2 
 
 337 
 
 80 years and over 
 
 30 
 
 1123 
 
 28 
 
 1179 
 
 9 
 
 1049 
 
 19 
 
 1252 
 
 2 
 
 676 
 
 • • • 
 
 • • • 
 
 2 
 
 985 
 
 Total . 
 
 465 
 
 83 
 
 410 
 
 87 
 
 159 
 
 69 
 
 251 
 
 103 
 
 55 
 
 65 
 
 14 
 
 36 
 
 41 
 
 90 
 
 mo 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Under 1 year. — 
 
 1 
 
 7 
 
 1 
 
 8 
 
 1 
 
 15 
 
 
 
 
 
 
 
 
 
 Betw. 1 and 2 yrs. 
 
 1 3 
 
 6 
 
 2 
 
 4 
 
 1 
 
 4 
 
 1 
 
 4 
 
 1 
 
 16 
 
 
 
 1 
 
 30 
 
 2 to 4 years.... 
 
 J 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 5 to 9 years.... 
 
 1 
 
 2 
 
 1 
 
 2 
 
 1 
 
 4 
 
 
 
 
 
 
 
 
 
 0 to 9 years... . 
 
 5 
 
 8 
 
 4 
 
 3 
 
 3 
 
 5 
 
 1 
 
 2 
 
 1 
 
 6 
 
 
 
 1 
 
 12 
 
 10 to 19 years.... 
 
 5 
 
 4 
 
 5 
 
 5 
 
 • • • 
 
 
 5 
 
 9 
 
 
 
 
 
 
 
 20 to 29 years.... 
 
 18 
 
 12 
 
 14 
 
 12 
 
 8 
 
 14 
 
 6 
 
 10 
 
 4 
 
 15 
 
 2 
 
 16 
 
 2 
 
 15 
 
 30 to 39 years.... 
 
 55 
 
 45 
 
 43 
 
 43 
 
 17 
 
 34 
 
 26 
 
 52 
 
 12 
 
 55 
 
 4 
 
 36 
 
 8 
 
 74 
 
 40 to 49 years.... 
 
 151 
 
 164 
 
 120 
 
 156 
 
 48 
 
 126 
 
 72 
 
 187 
 
 31 
 
 199 
 
 8 
 
 97 
 
 23 
 
 316 
 
 50 to 59 years.... 
 
 212 
 
 339 
 
 180 
 
 329 
 
 86 
 
 322 
 
 94 
 
 335 
 
 32 
 
 407 
 
 11 
 
 259 
 
 21 
 
 581 
 
 60 to 69 years.... 
 
 214 
 
 594 
 
 198 
 
 608 
 
 101 
 
 660 
 
 97 
 
 563 
 
 16 
 
 462 
 
 8 
 
 467 
 
 8 
 
 457 
 
 70 to 79 years.... 
 
 140 
 
 971 
 
 134 
 
 1026 
 
 63 
 
 1126 
 
 71 
 
 952 
 
 6 
 
 442 
 
 3 
 
 496 
 
 3 
 
 399 
 
 80 years and over 
 
 27 
 
 776 
 
 26 
 
 832 
 
 6 
 
 534 
 
 20 
 
 999 
 
 1 
 
 282 
 
 1 
 
 746 
 
 • • • 
 
 ... 
 
 Total . 
 
 827 
 
 113 
 
 724 
 
 116 
 
 332 
 
 108 
 
 392 
 
 124 
 
 103 
 
 95 
 
 37 
 
 70 
 
 66 
 
 119 
 
 * The rates for the deaths of 1911 are calculated on the 1910 population figures. Data 
 for deaths from cancer, according to distribution for age, color, and sex, are lacking for 
 1910. 
 
 life. The negro rate surpassed the white rate very considerably from the 
 thirtieth to the sixtieth year, instead of but slightly from the fiftieth to the 
 sixtieth years, as in 1911. In 1920, the rates for whites continued to rise until 
 the eightieth year and then declined, while the negro rates ran on a level 
 between the sixtieth and the eightieth years and declined through the re¬ 
 mainder of life. These deviations from the experience of 1911 are found on 
 
 29 
 
444 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 further analysis to be due mainly to marked increases in the rates for negro 
 females before the sixtieth year and declines after this period, and to a con¬ 
 siderable augmentation in the mortality for negro males throughout life 
 and particularly after the sixtieth year. 
 
 From the foregoing account of the relation of recorded deaths from cancer 
 and tumor to the Baltimore population, the following points stand out with 
 clear cut distinctness. As averaged for 5-year periods, the death-rates of these 
 two rubrics taken together increased from 4 for period 1812-1815 to 111 for 
 the 5 years ending in 1920, an increase of 2,650 per cent. This increase was 
 gradual and interrupted until 1860, and abrupt between 1860 and 1880. But 
 for a slight recession between 1881 and 1885 the rates rose continuously to 
 the end of the period. Of the great increase in the rates, 43 per cent occurred 
 in the period previous to 1885. Though before 1910 under the rubric tumor 
 there were doubtless included a not inconsiderable number of deaths due to 
 malignant or cancerous growths, both before and since this date, in compari¬ 
 son with the total mortality, its rate has been almost negligible. Therefore, 
 in analysis of various factors involved in explaining the marked increase in 
 the cancer death-rate, without seriously invalidating results, it may be safely 
 left out of the calculation. Like the death-rates for cancer and tumor com¬ 
 bined, those for cancer have shown their greatest proportion of increase since 
 1885. Since 1900, at least, both the white and the negro race and both sexes 
 have shared in this increase in recorded cancer mortality. In this period the 
 rates for cancer have been higher in females than in males, higher in the 
 aggregate in white than in negro females, higher in white than in negro males. 
 In addition to confirming these results, rates specific for age, calculated for 
 1911, indicate that under the fortieth and over the fiftieth years of age cancer 
 was considerably more fatal in whites than in negroes. 
 
 If these observations may be applied to the whole period under considera¬ 
 tion, it is obvious that, other things remaining equal, the cancer death-rate 
 would have been unfavorably influenced by relative increase in the population 
 of whites, especially of women, of females of both races, of whites 40 years 
 and over, and of negroes between the fortieth and the seventieth years. 
 
 As it has been found that of the deaths ascribed to cancer in 1911 and 1920 
 only a small proportion occurred in individuals below the fortieth year, and an 
 almost negligible proportion in those under the thirtieth year of age, it is nec¬ 
 essary, in reaching an approximately correct estimate of the influence of 
 changes in the age distribution of the population upon the rate of cancer mor¬ 
 tality, to disregard the lower age-groups and to consider only those portions 
 of the population above these two ages. Between 1830 and 1920 the percentage 
 of the population 40 years of age and over increased from 15.7 to 28.5 and 
 that 30 years and over from 29.2 to 54.8 of the whole, or by 75 and 55 per 
 cent, respectively. But this notable increase in the proportion of the popula¬ 
 tion in the age-period most susceptible to cancer was, however, in a ratio far 
 below the recorded increase in cancer mortality. Mortality-rates for cancer 
 and tumor for each of the census years between 1830 and 1920, calculated on 
 the basis of the population at all ages and the populations over the twenty- 
 ninth and thirty-ninth years of life, respectively, are given in table 105 and 
 graph 29. Whatever their specific differences, these rates follow the same gen¬ 
 eral course throughout. Each shows an ascent more or less gradual until 
 
VARIOUS CHRONIC ORGANIC DISEASES 
 
 445 
 
 Table 105 .—Number of deaths and rate of death per 100,000 living inhabitants, of the several 
 age groups, population at all ages, 30 years and over and 40 years and over, from cancer 
 and tumor and from senility and causes unknown in adults, for the census years 1830-1920, 
 inclusive. 
 
 D = death. R = rate. 
 
 Census 
 
 years. 
 
 Population, at all ages. 
 
 Of 30 years 
 and over. 
 
 Of 40 years and over. 
 
 Cancer. 
 
 Tumor. 
 
 Cancer 
 
 and 
 
 tumor. 
 
 Cancer. 
 
 Tumor. 
 
 . 
 
 S-. 
 
 <D O 
 
 v S 
 
 S 5 
 
 Cancer. 
 
 Tumor. 
 
 Cancer k 
 
 tumor. 
 
 Senility. 
 
 Causes 
 
 unknown. 
 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 R 
 
 R 
 
 R 
 
 R 
 
 R 
 
 
 D 
 
 I 
 
 R 
 
 D 
 
 R 
 
 1830 .... 
 
 6 
 
 7 
 
 1 
 
 1 
 
 7 
 
 9 
 
 18 
 
 3 
 
 21 
 
 26 
 
 4 
 
 31 
 
 102 
 
 450 
 
 43 
 
 190 
 
 1840 .... 
 
 9 
 
 9 
 
 3 
 
 3 
 
 12 
 
 12 
 
 29 
 
 10 
 
 39 
 
 56 
 
 19 
 
 75 
 
 104 
 
 651 
 
 32 
 
 200 
 
 1850 .... 
 
 14 
 
 8 
 
 3 
 
 2 
 
 17 
 
 10 
 
 26 
 
 6 
 
 32 
 
 48 
 
 10 
 
 59 
 
 155 
 
 535 
 
 94 
 
 325 
 
 1860 .... 
 
 30 
 
 14 
 
 4 
 
 2 
 
 34 
 
 16 
 
 42 
 
 6 
 
 47 
 
 75 
 
 10 
 
 85 
 
 197 
 
 492 
 
 144 
 
 360 
 
 1870 .... 
 
 49 
 
 18 
 
 8 
 
 3 
 
 57 
 
 21 
 
 51 
 
 8 
 
 60 
 
 87 
 
 14 
 
 101 
 
 288 
 
 513 
 
 141 
 
 251 
 
 1880 .... 
 
 174 
 
 52 
 
 34 
 
 10 
 
 208 
 
 63 
 
 139 
 
 27 
 
 167 
 
 226 
 
 44 
 
 270 
 
 252 
 
 327 
 
 14 
 
 18 
 
 1890 .... 
 
 256 
 
 59 
 
 25 
 
 6 
 
 281 
 
 65 
 
 151 
 
 15 
 
 166 
 
 247 
 
 24 
 
 271 
 
 365 
 
 352 
 
 6 
 
 6 
 
 1900 .... 
 
 338 
 
 67 
 
 35 
 
 7 
 
 373 
 
 73 
 
 164 
 
 17 
 
 181 
 
 268 
 
 28 
 
 296 
 
 357 
 
 283 
 
 • • • 
 
 • • • 
 
 1910 .... 
 
 502 
 
 90 
 
 27 
 
 5 
 
 529 
 
 95 
 
 209 
 
 11 
 
 220 
 
 331 
 
 18 
 
 349 
 
 191 
 
 126 
 
 ... 
 
 • • • 
 
 1920 .... 
 
 789 
 
 108 
 
 27 
 
 4 
 
 816 
 
 111 
 
 238 
 
 8 
 
 246 
 
 378 
 
 13 
 
 391 
 
 60 
 
 29 
 
 ... 
 
 
 Senility 
 
 and 
 
 causes 
 
 unknown. 
 
 D 
 
 R 
 
 136 
 
 249 
 
 341 
 
 429 
 
 266 
 
 371 
 
 357 
 
 191 
 
 60 
 
 145 640 
 
 851 
 860 
 
 852 
 764 
 345 
 358 
 283 
 126 
 
 29 
 
 * In each instance the figures for the number of deaths represent the average of three con¬ 
 secutive years, namely, the census year and the year immediately preceding and succeeding. 
 
 Graph 29 (from tables 105, 110 and 116). Mortality rates from tumor 
 (cancer and other tumors), cardio-vascular-renal diseases, and senility and 
 causes unknown in adults, specific for age-group 40 years of age and over, 
 for the census years 1830 to 1920, inclusive. 
 
446 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 1870 and a sharp rise to a much higher level in 1880. It will be noted that 
 between 1880 and 1890 all the rates were stationary. In the 30 years between 
 1890 and 1920, the rates, however calculated, exhibit progressive and con¬ 
 siderable increases. The percentages of these increases in different portions of 
 the period are shown in table 106. 
 
 It will be noted that the greater the degree of correction for the age-factor, 
 the smaller the percentage of increase in the rates. It will be recognized that 
 this method fails to account fully for the effect of the age-factor upon the rates 
 for cancer mortality, for here it has been assumed that all increase in the 
 proportional increase in the population above the twenty-ninth and thirty- 
 ninth years of age is of equal consequence in this respect. However, as the 
 risk of dying of cancer increases greatly and in rising ratios from decade to 
 decade of life (table 104) it is evident that increases in the population in the 
 higher decades, the sixth, seventh, and eighth, for instance, must exercise 
 a more marked influence upon the cancer risk than corresponding increases 
 in the fourth and fifth decades. As a matter of fact, in the period 1890-1920 
 
 Table 106 . — Percentage of increase from one period to 
 another of rates shown in Table 105. 
 
 Periods- 
 
 Population 
 
 of 
 
 all ages. 
 
 Population 
 30 years 
 and over. 
 
 Population 
 40 years 
 and over. 
 
 1890 to 1920 . 
 
 71 
 
 49 
 
 44 
 
 1890 to 1900 . 
 
 12 
 
 9 
 
 9 
 
 1900 to 1910 . 
 
 31 
 
 22 
 
 15 
 
 1910 to 1920 . 
 
 17 
 
 12 
 
 12 
 
 1880 to 1890 . 
 
 3 
 
 
 • • 
 
 the proportions of the population in the sixth, seventh, and eighth decades of 
 life increased by 21, 26, and 19 per cent, respectively, while the proportional 
 increases in th,e fourth and fifth decades were only 4 and 16 per cent. So, if 
 it were possible to calculate for each census year rates specific for each of these 
 decades of life, correction for the age-factor would become more striking. 
 When rates for cancer alone specific for age for the census years 1900, 1910, 
 and 1920 are applied to the respective age distribution of a standard popula¬ 
 tion (Glovers Life Table for the United States), a rise in the rate from 105 
 in 1900 to 173 in 1920, or an increase of 65 per cent, becomes apparent in this 
 21-year period as due to causes other than age influence. 
 
 Among the possible causes other than actual increase in incidence and 
 fatality of cancer, perhaps the most important that may be inquired into are 
 improvement in medical diagnosis and in statistical classification of deaths 
 in the health department. The influence of improvement in diagnosis may be 
 tested somewhat roughly in the following fashion: Deaths recorded as due to 
 cancer since 1875 can be separated with five fairly well-defined groups: 
 (1) breast, (2) female genitals (uterus, ovary, vagina, and pelvis), (3) 
 oesophagus, stomach, and liver, (4) intestines and peritoneum, and (5) all 
 other organs. The first four groups represent respectively rubrics numbers 
 
VARIOUS CHRONIC ORGANIC DISEASES 
 
 447 
 
 43, 42, 40, and 41 of the International Classification of Causes of Death, 
 revision of 1909. 
 
 Cancer of the breast, equivalent for practical purposes to cancer of the 
 female breast, is not only common enough, but in its fatal stage is easily 
 recognizable. It is the best example of accessible or open cancer of frequent 
 occurrence. It has presented, therefore, little opportunity for errors in diag¬ 
 nosis (in fatal stage) and of classification. Among the important organs not 
 directly on the surface and frequently the seat of fatal cancer, the uterus is 
 the most readily accessible to physical examination. Cancer of this organ can 
 rarely proceed to a fatal termination without giving rise to clinical symptoms 
 and physical signs which would not baffle the diagnostic powers of even a tyro 
 in medicine. Cancer of the ovary and “ of the pelvis,” the latter appearing 
 only occasionally in the records, is comparatively rare, and is easily recog¬ 
 nized at operation. Since 1876, however, but few women in Baltimore with 
 ovarian tumors can have escaped operation. Nor in this period has the diag¬ 
 nosis of the relatively rare primary cancer of the vagina and the external 
 genitals of the female in fatal stages presented any serious difficulty. In cancer 
 of all these organs the important problems have not been concerned with ulti¬ 
 mate but rather with early recognition, and with operative technique. Malig¬ 
 nant growths of the oesophagus, though not exposed to direct view and rela¬ 
 tively uncommon, before the fatal issue give rise to unmistakably characteristic 
 symptoms. While they may be confused with cancer of the cardiac end of the 
 stomach, since both belong to the same rubric, errors of differential diagnosis 
 as between cancer of these two organs are of no present consequence. The 
 diagnosis of cancer of the stomach, even yet often mistaken in fatal cases, has 
 certainly increased very greatly in accuracy since 1875. It was not until well 
 after this date that Dr. Saltzer specialized in diseases of the stomach and 
 introduced the newer methods of gastric analysis, and it was some years before 
 the routine use of chemical and microscopical methods in the diagnosis of 
 diseases of the stomach by Osier in his clinic, opened in 1889, was adopted in 
 other hospitals, and that private clinical laboratories were established. Nor 
 was it before 1900 that through the work of gastro-enterologists, consulting 
 internists, laboratory specialists (including roentgenologists), and surgeons, 
 that the present era of intensive study of diseases of the stomach may be said 
 to have opened in Baltimore. It is evident, therefore, that since 1876 the 
 recognition of gastric cancer in its last as well as in its earlier stages has 
 increased progressively in accuracy. As this organ is one of the most common 
 seats of primary cancer in both sexes, increased precision of diagnosis must 
 have exercised an important role in the observed rise in the crude rates 
 for cancer. 
 
 While primary cancer of the liver is comparatively rare, of the important 
 viscera this organ is the one which is most frequently the seat of diagnoseable 
 malignant growths originating in other parts of the body. So propitious are 
 conditions in this organ for the deposit and growth of metastases that, from 
 primary cancers in themselves relatively obscure, it is often the seat of sec¬ 
 ondary growths so prominent on account of their number and size as to fix 
 attention. While a large proportion of cancers of other organs of digestion, 
 as the oesophagus, stomach, intestines, and pancreas metastasize in the liver, 
 it is also often involved secondarily from malignant growths not only of other 
 
448 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 abdominal organs, notably the uterus, but of such distant parts as the extremi¬ 
 ties, the central nervous system, the eye, and the skin. In consequence, though 
 these pecularities of the liver often determine the recognition of cancer that 
 would be otherwise overlooked, likewise they are responsible not unfrequently 
 for errors in statistical classification. With the increase of knowledge of the 
 pathology of cancer and the improvement in diagnosis, doubtless in many 
 instances deaths, which in earlier years would have been credited to cancer 
 of the liver, have in more recent years been assigned in the statistical classifica¬ 
 tion to the proper organs of origin. On the whole, however, it may be assumed 
 that during the last 45 years the diagnosis of malignant growths falling 
 under our third group has undergone a very decided improvement. 
 
 The diagnosis of the relatively rare cancer of the small intestines has been 
 until recent years comparatively obscure. The diagnosis and statistical classi¬ 
 fication of cancer of the colon have without doubt increased greatly in precision, 
 but it is probable that a considerable proportion of deaths from cancer of the 
 small and large intestines (the rectum excepted) are still classified under in¬ 
 testinal obstruction and other rubrics. Cancer of the rectum is comparatively 
 accessible, and it is doubtful if in its terminal stage any marked improvement 
 in its diagnosis has occurred in the period under consideration. Primary 
 cancer of the peritoneum is so infrequent as to be of relatively minor im¬ 
 portance. 
 
 Cancer of “ all other organs ” embraces several distinct groups of malig¬ 
 nant tumors which vary widely in the ease with which they may be recog¬ 
 nized. Cancer of the skin (including the external genitals), the nasal and 
 buccal cavities, the eye, the larynx, the thyroid, the testes, the superficial 
 lymph-glands, the subcutaneous connective tissue, the skeletal muscles, and 
 the bones, which, taken together, represent a very considerable proportion of 
 all malignant growths, have presented, in their fatal stages at least, no great 
 difficulties in diagnosis that have been dissipated by recent advances in medi¬ 
 cal knowledge. In this respect they are, for the most part, directly comparable 
 with cancer of the breast and uterus. On the other hand, cancer of the lungs 
 and pleura, of the deeper lymphatic system, of the bladder, prostate, and kid¬ 
 neys, of certain abdominal organs, as the pancreas, the kidneys, and the 
 adrenals, and of the central nervous system compose a group numerically less 
 significant than the above and in which diagnosis has in late years achieved 
 very considerable progress. Out of this group, during the last 10 years, fell 
 growths of the brain, many of which are malignant. This error imposed by 
 official rules of statistical classification has been more than counterbalanced, 
 perhaps, by the dispersion to the proper organs of origin the members of the 
 old statistical group “ cancer diffused.” It seems likely, then, that in a sub¬ 
 stantial majority of instances the members of the category of “ cancer of all 
 other organs ” were as readily recognizable in 1876 as in 1920. There can be 
 no doubt that the increased frequency with which autopsies have been con¬ 
 ducted by trained pathological anatomists in both homes and hospitals since 
 the opening of the Johns Hopkins Hospital in 1889 has contributed very 
 materially to correctness of diagnosis and in consequence of statistical classifi¬ 
 cation of deaths due to tumors. 
 
 All things considered, on the basis of increase in precision of diagnosis 
 alone, there should be no rise in the mortality from cancer of the breast and 
 
VARIOUS CHRONIC ORGANIC DISEASES 
 
 449 
 
 uterus, but the advance in the rates for cancer of the oesophagus, stomach, and 
 liver should be considerable; in those for cancer of the intestines and peri¬ 
 toneum very marked; and, finally, the increase in the rates for cancer “ of all 
 other organs ” should be somewhat less than for cancer of the oesophagus, 
 stomach, and liver. The crude mortality rates for these various categories as 
 averaged for 5-year periods from 1876 to 1920, inclusive, are compared in 
 table 107. It will be observed that though the rate for each has risen, the 
 increases are by no means equal. While the total rate for cancer increased by 
 125 per cent and the rates for cancer of the breast and of the uterus (and 
 other female organs of generation) rose but by 67 and 42 per cent, respectively, 
 the rate for cancer of the oesophagus, stomach, and liver rose by 160 per cent, 
 and that for the intestines and peritoneum by 550 per cent. On the other 
 hand, the rate for cancer of “ all other organs ” rose by only 125 per cent, or 
 in the same proportion as the total cancer rate. The increase in the rates for 
 
 Table 107 .—Rate of death, per 100,000 living inhabitants, by 5-year periods, from 
 
 cancer, from 1876 to 1920, inclusive. 
 
 Period- 
 
 Grand 
 
 total. 
 
 Total 
 rubrics 40 
 and 41. 
 
 Rubric 40. 
 
 Rubric41. 
 
 Total 
 rubrics 42 
 and 43. 
 
 Rubric 42. 
 
 Rubric43. 
 
 All other 
 organs. 
 
 Stomach, 
 oesopha¬ 
 gus and 
 liver. 
 
 In¬ 
 
 testines, 
 
 rectum 
 
 and 
 
 perito¬ 
 
 neum. 
 
 Breast. 
 
 Uterus 
 
 ovaries 
 
 and 
 
 pelvis. 
 
 1876-80 . 
 
 47 
 
 17 
 
 15 
 
 2 
 
 18 
 
 6 
 
 12 
 
 12 
 
 1881-85 . 
 
 50 
 
 20 
 
 16 
 
 4 
 
 19 
 
 7 
 
 11 
 
 11 
 
 1886-90 . 
 
 57 
 
 25 
 
 20 
 
 5 
 
 22 
 
 8 
 
 14 
 
 10 
 
 1891-95 . 
 
 59 
 
 25 
 
 21 
 
 4 
 
 22 
 
 8 
 
 15 
 
 11 
 
 1896-1900 . 
 
 66 
 
 29 
 
 26 
 
 4 
 
 23 
 
 8 
 
 16 
 
 14 
 
 1901-05 . 
 
 76 
 
 38 
 
 31 
 
 8 
 
 21 
 
 8 
 
 13 
 
 16 
 
 1906-10 . 
 
 84 
 
 42 
 
 34 
 
 8 
 
 23 
 
 8 
 
 15 
 
 19 
 
 1910-15 . 
 
 98 
 
 48 
 
 37 
 
 11 
 
 25 
 
 9 
 
 15 
 
 26 
 
 1916-20 . 
 
 106 
 
 52 
 
 39 
 
 13 
 
 27 
 
 10 
 
 17 
 
 27 
 
 cancer of the breast and of the female generative organs was notably less than 
 it was in those for the other three categories, and the advance in the rates for 
 these latter categories varied roughly with the scope that was assumed to be 
 available for the effect of improvement in diagnosis. But it was assumed that 
 on the basis of improvement in diagnosis the rates for cancer of the breast 
 and of the female generative organs there should be no gain at all. In regard 
 to this point, it is significant that during most of the period, i. e., from 1886 
 to 1910, these rates were practically stationary. The slight ascents in these 
 rates in the periods before and after these dates may well be explained by 
 variables yet to be considered. 
 
 If the mortality for tumors as a whole and for cancer in particular has not 
 actually but only apparently risen in the striking ratio the official figures 
 would seem to indicate, under what statistical rubrics were the unaccounted- 
 for tumor deaths classified? ’While they may have been dispersed perhaps 
 under many rubrics through which it is now impossible to trace them, two 
 rubrics, causes unknown in adults and senility, probably received the majority. 
 
450 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 The rates for these averaged for 5-year periods are compared with those for 
 tumors in table 102. Similar comparisons are made for the census years 1830 
 to 1920, inclusive, in table 105. The decline in the rates for these indefinite 
 causes much more than counterbalances the ascent in the rates for tumors. 
 Though there is ample room in these rubrics for hidden cancer (as well as 
 for other causes of death improperly assigned), even if the higher rates of 
 later years represented no actual increase in cancer, this evidence is only sug¬ 
 gestive. Another heading under wdiich some cancer deaths may well be con¬ 
 cealed is intestinal obstruction, but as this is combined in the same rubric 
 with hernia, comparison is not here attempted. Since 1900, and particularly 
 since 1910, special care has been taken in the division of statistics of the 
 health department to secure full and accurate classification of deaths from 
 tumors. 
 
 In addition to the direct influence upon cancer mortality-rates, which it has 
 already been pointed out must be attributed to the perfection in the methods 
 of diagnosis and treatment during the last 30 or 40 years, there must be taken 
 into consideration the possibility of an indirect effect. It is a well-established 
 fact that since 1890 an ever-increasing number of individuals with cancer 
 have come to Baltimore from other places for advice and treatment. Some 
 proportion of these must inevitably die here. It is reasonable to suppose, then, 
 that the proportion of cancer deaths in non-residents was low in the early 
 period and high in recent years. Unfortunately, no data on this point are 
 recorded before 1917. However, in the 4 years 1917-1920, inclusive, on an 
 average, 17 per cent of all recorded deaths from malignant tumors were in 
 non-residents—almost all of whom, it is certain, were attracted to the city by 
 the reputation of its physicians and surgeons in diagnosis in general and in 
 the diagnosis and treatment of cancer in particular. It is inconceivable that 
 in early years non-residents could have accounted for anything approaching 
 such a high proportion of the total deaths from cancer. Unhappily, data in 
 regard to deaths of non-residents from benign tumors have not been tabulated, 
 but it is well known that each year an appreciable number of individuals from 
 out of town with growths of this type are operated on by local surgeons and 
 that some fail to survive the experiment. On the other hand, there is no evi¬ 
 dence that any significant proportion of residents with either cancer or benign 
 tumor died without the city. Therefore the conclusion is forced that a con¬ 
 siderable proportion of the increase in cancer mortality in later years is to be 
 attributed to this factor. 
 
 In respect of race, there has been a steady and decided decrease in the per¬ 
 centage of negroes since 1880. The increase of females over males in the gen¬ 
 eral population has hardly been great enough to influence the tumor-rate 
 significantly. 
 
 Though some of the increase in the recorded mortality previous to 1870 
 may well have been due to actual augmentation in the lethal force of tumor, 
 it is unreasonable to suppose that the enormous advance in the rates between 
 1870 and 1880 can be thus explained. The rates recorded for 1870 would 
 hardly have covered the expected mortality from all tumors readily diag- 
 noseable at that time. Evidently diagnosis and statistical classification of 
 tumors up to this time must have been poor. It is likely, then, that the enor¬ 
 mous increase in the tumor-rate for 1880 as compared with 1870 was due 
 
VARIOUS CHRONIC ORGANIC DISEASES 
 
 451 
 
 largely, if not entirely, to improvement in statistical classification of deaths 
 inaugurated in 1875 by Commissioner James A. Steuart, who was especially 
 interested in statistics. This view is supported by the facts that there was no 
 increase in the rates for cancer and tumor between 1880 and 1890, and in 
 these 10 years but little progTess was made in the precision of diagnosis of 
 cancer of internal organs. 
 
 If the foregoing observations and assumptions concerning the influence 
 of age, sex, race, improvements in diagnosis and statistical classification, and 
 the increase in the proportion of non-residents dying of cancer be correct, the 
 course of the rates for tumor (including cancer) can not be considered to 
 signify an actual increase in lethal force in the period up to 1890. If this be 
 true, the bulk of the hidden tumor deaths must have been classified under 
 some other rubric or rubrics for deaths among individuals 40 years of age and 
 over. It has been pointed out already that of these, senility and causes unknown 
 in adults are the most likely rubrics to contain them. 
 
 Since between 1880 and 1890 there was practically no increase in the rates 
 for tumors, however calculated, the further course of these affections covers 
 the 30 years since 1890. It has been shown that, since 1900, 35 per cent in 
 the increase in the mortality-rate is explained by changes in the age distribu¬ 
 tion of the population. Of the remainder, a large part must have been due to 
 advance in precision in medical diagnosis, continued improvement in statisti¬ 
 cal classification, and the probable augmentation of deaths of non-residents. 
 While they cast considerable doubt upon the question, these considerations 
 do not prove that there has been no real increase in the mortality from tumors 
 (including cancer) in Baltimore. Nor in this discussion has any offset been 
 allowed for any reduction in mortality that should have occurred, if surgeons 
 are correct in their claims of definite cures of cancer of certain organs and of 
 the successful removal of benign tumors of various organs, such as the uterus 
 and ovary, that if left alone must have caused deaths. 
 
 There remains yet another test that may be applied to this material, with 
 some hope of getting a clear-cut answer that will cover these objections so far 
 as cancer is concerned. The diagnosis of cancer of the breast and uterus in 
 lethal stages can not be justly held to have improved significantly since 1880. 
 However, since 1890, and particularly since 1900, operative technique for 
 their cure has certainly, as the result primarily of the work of Halsted and 
 Kelly and their associates, been greatly perfected, and of late years many other 
 capable surgeons have adopted like methods. If there has been no actual 
 increase in the mortality from cancer of these two organs, then rates specific 
 for sex and age should show no significant increase between 1880 and 1890, 
 and an actual and not insignificant decrease since the latter date. Rates 
 averaged for 5-year periods from 1876 to 1920, inclusive, for these two cate¬ 
 gories, in respect of the total female population, that is, rates specific for sex 
 alone, are given in table 108. Since 1880, the percentages of increase in mor¬ 
 tality were, for the breast 43, for the uterus 50, and for the two together 47. 
 It is noteworthy that for cancer of the uterus these rates showed a little change 
 between 1895 and 1915; and that those for cancer of the breast were prac¬ 
 tically stationary from 1880 to 1910. For cancer of the breast since 1910 
 and for cancer of the uterus since 1915 these rates advanced considerably. As 
 for practical purposes deaths from cancer of the breast and uterus may be 
 
452 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 taken as confined to the age-period 40 years and over, and, since 1880, the 
 population figures of this age-gronp for females is available, it is possible to 
 calculate rates reasonably specific for the actual population exposed to the 
 risk of death from cancer of these organs for the census years 1880 to 1920, 
 inclusive. From these data, presented in table 109, it appears that after 1880 
 there was no increase in mortality from cancer of the breast, and since 1890 
 
 Table 108 .—Rate of death, 'per 100,000 living female inhabitants, by averaged 5-year 
 periods, from cancer of the breast, uterus, ovaries, and pelvis, from 1876 to 1920, 
 inclusive. 
 
 Period. 
 
 Total. 
 
 Breast. 
 
 Uterus, 
 
 ovaries 
 
 and 
 
 pelvis. 
 
 Period. 
 
 Total. 
 
 Breast. 
 
 Uterus, 
 
 ovaries 
 
 and 
 
 pelvis. 
 
 1876-80 . 
 
 34 
 
 12 
 
 22 
 
 1901-05 . 
 
 40 
 
 15 
 
 25 
 
 1881-85 . 
 
 36 
 
 14 
 
 22 
 
 1906-10 . 
 
 45 
 
 16 
 
 30 
 
 1886-90 . 
 
 42 
 
 16 
 
 26 
 
 1911-15 . 
 
 48 
 
 18 
 
 30 
 
 1891-95 . 
 
 43 
 
 15 
 
 28 
 
 1916-20 . 
 
 53 
 
 20 
 
 33 
 
 1896-1900 _ 
 
 44 . 
 
 14 
 
 30 
 
 
 
 
 
 none from cancer of the uterus. On the contrary, since 1910, there has been 
 a notable decrease in mortality from cancer of the breast, and since 1890 from 
 cancer of the uterus and from cancer of these two organs taken together. Thus, 
 when rates that approach specificity are obtained, in respect to cancer of these 
 two organs, in which the disease in fatal stages is readily diagnoseahle, an 
 apparent increase in mortality is converted into an actual decrease. Therefore 
 
 Table 109 .—Number of deaths and the rate of death, per 
 100,000 living female inhabitants, JfO years of age 
 and over, from cancer of the breast and uterus, for 
 the census years 1880 to 1920, inclusive. 
 
 D = death. R = rate. 
 
 Year. 
 
 Popula¬ 
 
 tion. 
 
 Total. 
 
 Breast. 
 
 Uterus. 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 1880 . 
 
 40936 
 
 94 
 
 230 
 
 37 
 
 90 
 
 57 
 
 139 
 
 1890 . 
 
 59278 
 
 158 
 
 286 
 
 50 
 
 90 
 
 108 
 
 195 
 
 1900 . 
 
 66811 
 
 161 
 
 241 
 
 52 
 
 78 
 
 109 
 
 162 
 
 1910 . 
 
 80079 
 
 199 
 
 249 
 
 74 
 
 93 
 
 125 
 
 156 
 
 1920 . 
 
 106902 
 
 205 
 
 192 
 
 80 
 
 75 
 
 125 
 
 117 
 
 it seems to be established that, during the last 40 years, cancer of the breast 
 and uterus (including the other female organs of generation) has shown no 
 real advance in mortality, and that there is a considerable margin of reduc¬ 
 tion, especially in respect of the latter category, to be placed probably to the 
 credit of surgical interference. 
 
 As the operative mortality for cancer of these two seats is comparatively 
 slight, the question of deaths among non-residents is here relatively of neg¬ 
 ligible importance. 
 
VARIOUS CHRONIC ORGANIC DISEASES 
 
 453 
 
 Since 1890 these speciiic rates for cancer of the breast and uterus have fallen 
 by 25 and 42 per cent, respectively. As spontaneous recovery from cancer of 
 these organs is unknown, unless the disease has decreased correspondingly in 
 incidence—and for this there is no evidence—these figures may be taken as 
 measuring in a general way the effect upon mortality of earlier diagnosis and 
 improved measures of mechanical treatment. It is not unreasonable to sup¬ 
 pose that in the last 20 years at least comparable results have been obtained 
 in cancer of some certain other organs, such as the skin, lip, tongue, bones, 
 and rectum, and that cures have been made at least occasionally of cancers 
 of other organs. 
 
 These disclosures in regard to cancer of these two accessible organs indicate 
 very definitely that such proportions of the advances in the crude rates for 
 cancer of all other organs as are not dependent upon changes in the age, sex, 
 and race distribution of the population should be attributed to improvements 
 in diagnosis and statistical classification and to relative increases in the num¬ 
 ber of deaths of non-residents with cancer coming to the city for diagnosis 
 and treatment and not to an actual increase in mortality. In regard to benign 
 tumors, it will be noted from table 102 that there was but little increase in the 
 crude rates for tumors between 1890 and 1905 and an actual decrease since 
 the latter date. Tins means that, when corrected for age, the rate for tumor 
 unqualified has declined in the last 30 years and that most of this decline has 
 occurred since 1905. After 1890, at least, most of the deaths ascribed to tumor 
 were associated with benign tumors of the uterus and ovary. It is evident, 
 then, that in this period there has been a fall in the death-rate from tumors of 
 this class. In Baltimore gynaecologists and general surgeons have been operat¬ 
 ing with success upon such tumors of the ovary since 1870 and of the uterus 
 since 1890. The situation is complicated, however, by the fact that a large 
 proportion of the operations and a considerable proportion of the deaths were 
 in non-residents. On the whole, the decline in the rates for benign tumors 
 may be taken probably as indicative of improved surgical technique. No 
 administrative measures designed to influence the incidence and mortality of 
 cancer have been undertaken. 
 
Chapter XIV.—Diseases of the Cardio-vascular- 
 
 renal System. 
 
 (Tables 101, 110 to 116, graphs 27 to 29.) 
 
 Under this general heading will be discussed the course of recorded mor¬ 
 tality from certain affections of the heart, blood-vessels, and kidneys. Some 
 of these affections are almost hopelessly mixed, and in many instances it is 
 impossible to decide definitely, even at autopsy, to which one of several cate¬ 
 gories a particular death should be classified. But slight experience in this 
 field reveals convincing evidence that in many instances the classification of 
 a given death to one rubric instead of to another is determined by the chance 
 that a physician used one term instead of another equally appropriate to define 
 either the primary or the secondary cause of death. This complication has 
 been accentuated in some respects by the classification rules of the Bureau of 
 the Census. It will soon appear that it has not been possible to follow and to 
 include all of the rubrics under diseases of the circulation and of the kidneys. 
 Because diseases of the venous system, thrombosis, and calculi and suppurative 
 affections of the kidneys could not be traced and accounted for in the earlier 
 years, they have been omitted from consideration in later years. Nor is it 
 possible in the available data to study acute and chronic affections separately. 
 
 The diseases of the organs under immediate consideration occur in the 
 statistical nosology under a variety of headings, which for convenience are here 
 assembled under the following rubrics: Organic diseases of the heart, apoplexy 
 and softening of the brain, arterio-sclerosis, Bright’s disease of the kidneys, 
 and general dropsy. After a brief account of the evolution of these rubrics, 
 the course of the recorded mortality for each will be traced, and then the group 
 as a whole will be considered. 
 
 Deaths from affections of the heart appeared in the mortality tables for the 
 first time in 1824 under the heading organic disease of the heart, a statistical 
 rubric which has persisted ever since. With the considerable expansion of the 
 lists of the causes of death after 1875, as refinements of classification there 
 were added numerous other rubrics, such as pericarditis, endocarditis, acute 
 and chronic, mitral and aortic regurgitation, cardiac dropsy, and the like. 
 Angina pectoris, after appearing in 1827, disappeared completely until 1875, 
 and during those 40-odd years deaths from this cause were classified under 
 organic diseases of the heart. Since 1875 deaths have been attributed to 
 angina pectoris in each year. After the adoption of the international list of 
 the causes of death in 1899, deaths attributed to affections of the heart have 
 been distributed among four rubrics—pericarditis, endocarditis, organic dis¬ 
 ease of the heart, and angina pectoris. It is evident from the foregoing that 
 these rubrics can not be traced consistently before the latter date, and that 
 the old statistical rubric, organic disease of the heart, as used before 1875, 
 embraced all deaths certified as due to disease of any of the various structural 
 454 
 
VARIOUS CHRONIC ORGANIC DISEASES 
 
 455 
 
 portions of this organ and therefore deaths classifiable under these four mod¬ 
 ern rubrics. On this account, in any attempt to trace correctly the course of 
 the force of mortality of cardiac affections associated with structural changes, 
 it is necessary to treat these under one generic heading, organic diseases of 
 the heart. 
 
 In this connection, for the sake of clearness, it may be pointed out that, 
 as used in contrast to pericarditis, acute endocarditis, and angina pectoris, 
 the rubric organic disease of the heart in the international system of classifica¬ 
 tion of causes of death from 1900 to 1920 is absolutely illogical and may lead 
 the unwary into serious error. The adjective organic is here used to indicate 
 disease of structure as opposed to aberrations of function alone. Pericarditis 
 and acute endocarditis, however, convey the concept, disease of organic struc¬ 
 ture, just as positively and as clearly as do myocarditis and chronic endocarditis, 
 which as certified causes of death are classed with some others under organic 
 diseases of the heart. The rubric under criticism is designed to include deaths 
 from other organic diseases of the heart than those which by definition are 
 embraced under the three remaining rubrics. While angina pectoris without 
 structural changes demonstrable by ordinary methods may in exceptional cases 
 be fatal, in the great bulk of cases which have been examined at autopsy by 
 competent pathologists very definite structural changes in the arteries, muscles, 
 or valves of the heart have been demonstrated. In the present section the term 
 organic disease of the heart is used in its broad and proper sense, and the 
 figures presented for each year represent the sum of the deaths recorded under 
 any and all rubrics implying structural changes of the heart, including the 
 pericardium. Angina pectoris is the only one of these rubrics that can be 
 followed separately for any considerable number of years. 
 
 Previous to 1899, deaths from apoplexy (including cerebral congestion and 
 hemorrhage) and softening of the brain were recorded in each year, under 
 apoplexy from 1813, congestion of the brain from 1841, and hemorrhage of 
 the brain from 1875. During the years in which these three rubrics occurred 
 together, apoplexy was always credited with the largest number of deaths, and, 
 on the whole, next in importance stood congestion of the brain. In 1899 these 
 three categories were combined in the single rubric, congestion and hemorrhage 
 of the brain and apoplexy, and with the revision of the international classifica¬ 
 tion effective in 1910 this became rubric 64. However, before 1875, the mor¬ 
 tality reports carried the rubric hemorrhage without specified organ, to which 
 doubtless some deaths actually due to cerebral hemorrhage were assigned. 
 To the rubric softening of the brain, since its introduction in 1868, deaths 
 have been credited in every year except 1898. In some of the earlier years 
 after its introduction the number of deaths assigned to this rubric amounted 
 to as much as one-third of the number classified under apoplexy, but since 1890 
 the rubric softening of the brain has steadily declined in relative importance. 
 
 In this section the deaths classified under congestion and hemorrhage of the 
 brain and apoplexy have been placed under a single rubric corresponding to 
 the present rubric 64 of the international classification, and thus for conven¬ 
 ience will be called apoplexy. There can be no doubt that the two rubrics of 
 the statistical nosology, apoplexy and softening of the brain, have been used 
 throughout the whole period for deaths due to affections falling under the same 
 
456 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 clinical and anatomical categories, namely, loss of consciousness with paraly¬ 
 sis, caused in the vast majority of instances by lesions of the cerebral blood¬ 
 vessels. For present purposes it is unimportant, whether the resulting injury 
 to the brain be brought about directly by anaemia due to closure of blood¬ 
 vessels from thrombosis, embolism, sclerosis, or by spasmodic contraction of 
 the cerebral vessels, resulting or not in necrosis (with softening) of brain 
 tissue, or by pressure (and anaemia) cause by oedema or by actual vascular 
 rupture with hemorrhage. As a matter of fact, in many instances, differential 
 diagnosis can be made with certainty only at autopsy. In any case, the injury 
 to the brain is almost always secondary to lesions primarily vascular, and in 
 the great majority of cases associated with hemorrhage into the brain-tissue. 
 In a certain proportion of instances apoplexy is caused by the plugging of one 
 or more cerebral vessels by emboli from the heart, usually associated with acute 
 endocarditis, and in recent times a large moiety of deaths so caused have been 
 assigned under the rules to the primary cardiac disease. 
 
 No direct recognition of arterial disease appeared in the mortality tables 
 until 1875, when 7 deaths were classified under aneurism. In each succeeding 
 year until 1899, with one exception, a few deaths were assigned to this rubric. 
 The highest number in any one year was 20 in 1897. In 1898, to the new 
 rubrics, atheroma and arterial sclerosis, a few deaths were credited. In 1899, 
 these three rubrics were combined in the single rubric, diseases of the arteries, 
 which has since grown steadily in importance. 
 
 The earliest mention of renal affections in the mortality records was in 1822, 
 when 1 death was recorded from nephritis, a term which did not appear again 
 until 1847. Inflammation of the kidneys, credited with 1 death in 1828, and 
 with from 1 to 2 deaths in 9 of the following 19 years, appeared in the statisti¬ 
 cal nosology each year between 1854 and 1897. For most of this period this 
 was the chief rubric under which deaths from renal disease were recorded. 
 To albuminuria, which appeared first in 1875, a few deaths were attributed 
 nearly every subsequent year until 1899. The rubric Bright’s disease, intro¬ 
 duced for the first time in 1872, gradually increased relatively in importance 
 and after 1898 completely superseded the other rubrics and became the sole 
 statistical repository for deaths from non-suppurative diseases of the kidneys. 
 In a few years before 1899, 1 or 2 deaths were attributed to renal calculi or 
 to renal abcess. Not until 1899 was a clear-cut attempt made to distinguish 
 between deaths due to Bright’s disease in the ordinary medical meaning of 
 the term and those due to affections of the kidneys associated with calculi 
 and with primary and secondary tuberculosis and suppuration of these organs. 
 However, since these affections are relatively rare as compared with Bright’s 
 disease, for the present discussion they may be disregarded. Since 1900 acute 
 and chronic Bright’s disease have been classified separately. 
 
 The rubric dropsy or general dropsy appeared continuously in the mortality 
 tables from 1812 to very recent years. As illustrative of its importance in the 
 statistical nosology in earlier times, in typical years the number of deaths 
 assigned to this rubric were 58 in 1827, 57 in 1840, 118 in 1850, 149 in 1860, 
 195 in 1870. In some years these figures were greatly exceeded. Between 
 1875 and 1898 this rubric was split into general, cardiac, renal, and ab¬ 
 dominal dropsy. After 1875, with the rapid and continuous expansion of 
 rubrics for heart disease, general dropsy steadily decreased in importance, and 
 
VARIOUS CHRONIC ORGANIC DISEASES 
 
 457 
 
 by 1910 had become insignificant. In the compilation of the tables for this 
 section, deaths from cardiac and renal dropsy have been assigned to heart and 
 renal diseases, respectively, and deaths from abdominal dropsy to cirrhosis of 
 the liver. Under dropsy have been tabulated only deaths classified as due to 
 dropsy unqualified and to general dropsy. 
 
 With the foregoing explanation of the sources and the order of the data at 
 hand, consideration of the course of mortality under the several rubrics will 
 be undertaken. The number of officially recorded deaths each year between 
 
 Table 110 .—Average rate of death, per 100,000 living inhabitants, by 5-year periods, 
 from diseases of the cardio-vascular-renal system, senility, causes unknown (adult), 
 and tumors, from 1812 to 1920, inclusive. 
 
 Periods. 
 
 Cardio-vascular-renal system. 
 
 Senility and 
 causes unknown. 
 
 Grandtotal cardio-vascular- 
 
 renal system, senility 
 
 and causes unknown- 
 
 Total tumors. 
 
 Diseases of the 
 heart. 
 
 Dropsy. 
 
 Aneurysm and 
 arterio-sclerosis- 
 
 Nephritis. 
 
 Total, excluding 
 apoplexy and soft¬ 
 ening of the brain. 
 
 Apoplexy and soft¬ 
 ening of the brain. 
 
 1 
 
 Total. 
 
 -4-> 
 
 •H 
 
 • H 
 
 3 
 
 <u 
 
 m 
 
 Causes unknown 
 
 (adult). 
 
 Total- 
 
 1812-15 . 
 
 
 82 
 
 
 
 82 
 
 10 
 
 92 
 
 145 
 
 
 145 
 
 237 
 
 4 
 
 1816-20 . 
 
 
 71 
 
 
 
 71 
 
 38 
 
 109 
 
 123 
 
 
 123 
 
 232 
 
 8 
 
 1821-25 . 
 
 3 
 
 58 
 
 
 
 61 
 
 24 
 
 85 
 
 120 
 
 39 
 
 159 
 
 244 
 
 6 
 
 1826-30 . 
 
 3 
 
 64 
 
 
 • • • • 
 
 67 
 
 17 
 
 84 
 
 119 
 
 56 
 
 175 
 
 259 
 
 9 
 
 1831-35 . 
 
 7 
 
 33 
 
 
 i 
 
 41 
 
 25 
 
 66 
 
 126 
 
 30 
 
 156 
 
 222 
 
 8 
 
 1836-40 . 
 
 7 
 
 49 
 
 
 i 
 
 57 
 
 21 
 
 78 
 
 95 
 
 22 
 
 117 
 
 195 
 
 11 
 
 1841-45 . 
 
 20 
 
 36 
 
 
 i 
 
 57 
 
 16 
 
 73 
 
 76 
 
 40 
 
 116 
 
 189 
 
 11 
 
 1846-50 . 
 
 27 
 
 57 
 
 
 2 
 
 86 
 
 18 
 
 104 
 
 96 
 
 74 
 
 170 
 
 274 
 
 13 
 
 1851-55 . 
 
 36 
 
 75 
 
 
 3 
 
 114 
 
 25 
 
 139 
 
 100 
 
 56 
 
 156 
 
 295 
 
 14 
 
 1856-60 . 
 
 45 
 
 64 
 
 
 5 
 
 114 
 
 24 
 
 138 
 
 94 
 
 73 
 
 167 
 
 305 
 
 13 
 
 1861-65 . 
 
 42 
 
 70 
 
 
 3 
 
 115 
 
 17 
 
 132 
 
 85 
 
 63 
 
 148 
 
 280 
 
 16 
 
 1866-70 . 
 
 50 
 
 81 
 
 
 6 
 
 137 
 
 21 
 
 158 
 
 89 
 
 62 
 
 151 
 
 309 
 
 23 
 
 1871-75 . 
 
 62 
 
 68 
 
 
 15 
 
 145 
 
 42 
 
 187 
 
 100 
 
 36 
 
 136 
 
 323 
 
 30 
 
 1876-80 . 
 
 84 
 
 22 
 
 1 
 
 31 
 
 138 
 
 70 
 
 208 
 
 72 
 
 4 
 
 76 
 
 284 
 
 54 
 
 1881-85 . 
 
 107 
 
 15 
 
 2 
 
 43 
 
 167 
 
 70 
 
 237 
 
 77 
 
 3 
 
 80 
 
 317 
 
 50 
 
 1886-90 . 
 
 109 
 
 7 
 
 3 
 
 60 
 
 179 
 
 78 
 
 257 
 
 74 
 
 1 
 
 75 
 
 332 
 
 63 
 
 1891-95 . 
 
 119 
 
 7 
 
 3 
 
 88 
 
 217 
 
 82 
 
 299 
 
 80 
 
 
 80 
 
 379 
 
 64 
 
 1896-1900 . 
 
 122 
 
 4 
 
 9 
 
 120 
 
 255 
 
 77 
 
 332 
 
 65 
 
 
 65 
 
 397 
 
 73 
 
 1901-05 . 
 
 142 
 
 2 
 
 22 
 
 143 
 
 309 
 
 74 
 
 383 
 
 54 
 
 
 54 
 
 437 
 
 83 
 
 1906-10 . 
 
 163 
 
 1 
 
 24 
 
 170 
 
 358 
 
 66 
 
 424 
 
 41 
 
 
 41 
 
 465 
 
 89 
 
 1911-15 . 
 
 172 
 
 • • • • 
 
 38 
 
 171 
 
 381 
 
 86 
 
 467 
 
 28 
 
 .... 
 
 28 
 
 495 
 
 102 
 
 1916-20 . 
 
 194 
 
 • • • • 
 
 25 
 
 169 
 
 388 
 
 120 
 
 508 
 
 12 
 
 
 12 
 
 520 
 
 110 
 
 1824 and 1920 from organic disease of the heart as above defined and the 
 mortality-rates calculated therefrom are given in table 101. With rather wide 
 fluctuations from year to } r ear the mortality-rates rose from 3 in 1824 to 10 in 
 1835, 17 in 1840, 32 in 1846, 49 in 1851, and 63 in 1870. With considerable 
 annual variations, the rates rose gradually during the next three decades to 
 126 in 1900. From this date there was an almost uninterrupted ascent in the 
 rates to 248 in 1918, with an abrupt fall to 167 in 1919, succeeded by a rise 
 to 180 in 1920. 
 
 The annual rates averaged for quinquennial periods (table 110) show no 
 significant rise between 1821 and 1840. Except for a slight setback for the 
 
458 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 period 1861-1865, there was a steady ascent in the averaged rates from 20 for 
 the quinquennium 1841-1845, to 62 for that ending in 1875. The rate of 
 increase was considerably accelerated during the next 10 years, but there 
 was no significant advance during the quinquennium 1886-1890. From 109 
 for the latter period, the rates advanced to 119 for 1891-1895, and after again 
 remaining almost stationary for the succeeding 5 years, they jumped steadily 
 upwards after 1901, and for the period ending in 1920 stood at 194. 
 
 The influence of age upon mortality from organic diseases of the heart in 
 1920 upon the whole population and upon whites and negroes taken sepa¬ 
 rately is shown in table 111. The data used include deaths recorded officially 
 under pericarditis, endocarditis, organic disease of the heart, and angina pec¬ 
 toris, but not those under congenital malformation. For the whole population 
 
 Table 111 .—Number of deaths and rate of death, per 100,000 living inhabitants, from 
 organic diseases of the heart, according to age, color, and sex, for 1920. 
 
 D = death. R = rate. 
 
 Age-period. 
 
 Total. 
 
 White. 
 
 Colored. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 Under 1 year. 
 
 
 
 
 
 
 
 
 
 
 .... 
 
 
 
 
 
 1 to 4 years. 
 
 3 
 
 6 
 
 1 
 
 2 
 
 . . . 
 
 .... 
 
 1 
 
 4 
 
 o 
 
 31 
 
 1 
 
 32 
 
 1 
 
 30 
 
 5 to 9 years. 
 
 11 
 
 17 
 
 10 
 
 18 
 
 4 
 
 14 
 
 6 
 
 22 
 
 1 
 
 12 
 
 1 
 
 26 
 
 • • • 
 
 • • • • 
 
 0 to 9 years. 
 
 14 
 
 10 
 
 11 
 
 9 
 
 4 
 
 7 
 
 7 
 
 12 
 
 3 
 
 18 
 
 2 
 
 25 
 
 1 
 
 12 
 
 10 to 19 years. 
 
 42 
 
 34 
 
 31 
 
 29 
 
 20 
 
 38 
 
 11 
 
 20 
 
 11 
 
 69 
 
 4 
 
 57 
 
 7 
 
 79 
 
 20 to 29 years. 
 
 60 
 
 41 
 
 37 
 
 31 
 
 18 
 
 31 
 
 19 
 
 32 
 
 23 
 
 89 
 
 13 
 
 107 
 
 10 
 
 73 
 
 30 to 39 years. 
 
 98 
 
 80 
 
 61 
 
 61 
 
 30 
 
 59 
 
 31 
 
 62 
 
 37 
 
 170 
 
 25 
 
 226 
 
 12 
 
 111 
 
 40 to 49 years. 
 
 168 
 
 182 
 
 97 
 
 126 
 
 51 
 
 134 
 
 46 
 
 119 
 
 71 
 
 456 
 
 42 
 
 507 
 
 29 
 
 398 
 
 50 to 59 years. 
 
 253 
 
 404 
 
 178 
 
 325 
 
 108 
 
 405 
 
 70 
 
 250 
 
 75 
 
 954 
 
 35 
 
 825 
 
 40 
 
 1107 
 
 60 to 69 years. 
 
 276 
 
 767 
 
 224 
 
 688 
 
 113 
 
 738 
 
 111 
 
 644 
 
 52 
 
 1501 
 
 25 
 
 1459 
 
 27 
 
 541 
 
 70 to 79 years. 
 
 292 
 
 2026 
 
 268 
 
 2052 
 
 117 
 
 2090 
 
 151 
 
 2024 
 
 24 
 
 1770 
 
 13 
 
 2149 
 
 11 
 
 1465 
 
 80 years and over. 
 
 163 
 
 4684 
 
 154 
 
 4926 
 
 49 
 
 4363 
 
 105 
 
 5242 
 
 9 
 
 2542 
 
 2 
 
 1493 
 
 7 
 
 3182 
 
 Total . 
 
 1366 
 
 186 
 
 1061 
 
 170 
 
 510 
 
 165 
 
 551 
 
 174 
 
 305 
 
 282 
 
 161 
 
 302 
 
 144 
 
 260 
 
 by decennial periods the rates were 10 for the first, 34 for the second, 41 for 
 the third, 80 for the fourth, 182 for the fifth, 404 for the sixth, 767 for the 
 seventh, 2,026 for the eighth, and 4,684 for the eightieth year and over. The 
 mortality, but slight before the thirtieth year, increases progressively from 
 this period into old age. For every age-group below the seventieth year, the 
 force of mortality is higher in negroes than in whites and for every decade of 
 life from the first to the seventh, inclusive, the mortality-rate for the former 
 is more than double that for the latter. From the thirtieth year in whites 
 and from the twentieth in negroes the rates increase sharply and progressively 
 with advancing years. In the white race the mortality in females is consider¬ 
 ably higher than that for males in the first decade of life, with rates of 12 
 and 7, respectively. This condition is reversed in the second decade, but 
 between the twentieth and thirty-ninth years the rates for the two sexes 
 are almost identical. Beween the fortieth and the seventy-ninth years the 
 mortality-rates are decidedly higher in males, but from the eightieth year the 
 
VARIOUS CHRONIC ORGANIC DISEASES 
 
 459 
 
 advantage is with the latter. Among negroes, below the tenth year the rate 
 for males is double that for females. In the second, sixth, and seventh decades 
 and over 80 years the chances of dying of cardiac disease is considerably less 
 for males than for females, but in the remaining decades the advantage is 
 with the females. For this particular year the rates for all ages for these sepa¬ 
 rate categories were: Whole population, 186; total whites, 169; white males, 
 165; white females, 174; total negroes, 282; negro males, 302; negro females, 
 260. Thus, the rates were considerably higher in negroes than in whites, and 
 somewhat higher in white females than in white males and in negro males 
 than in negro females. 
 
 It is evident that variations in the proportion of the population over 30 
 years of age and in the ratios of whites to negroes and of males to females 
 must have very materially influenced the course of the mortality from cardiac 
 disease. Changes in the age distribution of the population can not have 
 exerted any marked influence upon the recorded mortality-rates since 1830, 
 for, when these rates are corrected for this factor, it appears that not more 
 than 5 per cent of the advance can be so explained. 
 
 In table 101 the course of the annual mortality-rates for the rubrics apo¬ 
 plexy and softening of the brain may be followed. Studying the combined 
 rates, and omitting from consideration the figures for 1816 (which are given 
 under the heading apoplexy) as subject to large error, it will be observed that 
 the rate rose with some fluctuations from the very low level of 5 in 1813 to 
 40 by 1821. During the next 30 years the rate varied from 4 in 1826 to 36 
 in 1833, and in 1845 stood at 11. Between 1846 and 1874 there was no con¬ 
 siderable rise in the rates, but the annual variation became less marked. As 
 the rates jumped from 34 in 1874 to 79 in 1875, and as after this date never 
 but once (1909) fell below 60, it would appear that the rates were affected 
 considerably by the introduction of death certificates in the latter year. With 
 exceptionally high rates in only a few years (85 in 1893, 93 in 1895, 91 in 
 1913, and 86 in 1914), there was remarkably little change in the rates between 
 1875 and 1915. Rising abruptly to 109 in 1915, the rate reached the unusually 
 high level of 135 by 1918, to fall to 112 by 1920. 
 
 Passing now to rates averaged for 5-year periods (table 110), it will be 
 noted that the rate, after rising abruptly from 10 for 1812-1815 to 38 for 
 1816-1820, fluctuated between 16 as the lowest and 42 as the highest for any 
 quinquennial period until 1875. The course of the rates during these 60 years 
 is marked by instability. Having risen to 70 for the 5 years 1876-1880, and 
 retained this level for the succeeding quinquennium, the rates rose to 78 between 
 1886 and 1890, and to 82 between 1891 and 1895. During the next 15 years 
 there was a gradual recession, and for the quinquennium 1906-1910, the rate 
 stood at 66. During the period 1911-1915, though there was an upward turn 
 to 86, the rate was not markedly above the highest previous level. The rise 
 during the next quinquennium to 120, due largely but by no means entirely 
 to the excessively high rates of 135 in 1918, the year of the great influenza 
 epidemic, showed not only a marked increase over the period immediately 
 preceding, but well nigh a doubling in the rate within 10 years. 
 
 As measured by the experience of 1920 (table 112), the mortality-rates for 
 this rubric were decidedly higher for negroes than for whites, and for males 
 than for females in both races. The influence of age is conspicuous. The rates 
 30 
 
460 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 are negligible below the thirtieth year both in whites and in negroes, and 
 relatively insignificant in whites until the fifth decade of life. Among the 
 whites the greater mortality in females over males occurs in all the age dis¬ 
 tributions below the sixtieth year, and after this age the advantage is slightly 
 with the female, except between 70 and 80. Among negroes the mortality is 
 markedly higher in females than in males for each age-group below the 
 eightieth year. Not until extreme old age—80 years and over—do the rates 
 for negroes fall below those for whites. 
 
 The rates for renal disease, exclusive of tumors and as previously qualified, 
 averaged for 5-year periods, are given in table 110. It is evident that until 
 1890, at least, these rates measure rather the degree of the recognition than 
 
 Table 112. —Number of deaths and rate of death, per 100,000 living inhabitants, 
 from apoplexy, according to age, color, and sex, for 1920 * 
 
 D = death. R = rate. 
 
 Age-period- 
 
 Total. 
 
 White. 
 
 Colored. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 Total. 
 
 Male. 
 
 Fern. 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 Under 1 year . 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 to 4 years . 
 
 
 
 
 .... 
 
 
 
 
 
 
 
 
 
 
 
 5 to 9 years. 
 
 
 
 
 .... 
 
 
 
 
 
 
 
 
 
 
 
 0 to 9 years. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 10 to 19 years. 
 
 1 
 
 1 
 
 
 
 
 
 
 
 1 
 
 6 
 
 • .• • 
 
 • • • • 
 
 1 
 
 11 
 
 20 to 29 years . 
 
 3 
 
 2 
 
 3 
 
 3 
 
 3 
 
 5 
 
 
 
 
 
 
 
 
 
 30 to 39 years . 
 
 25 
 
 20 
 
 11 
 
 11 
 
 4 
 
 8 
 
 7 
 
 14 
 
 14 
 
 64 
 
 5 
 
 45 
 
 9 
 
 84 
 
 40 to 49 years . 
 
 75 
 
 81 
 
 38 
 
 50 
 
 18 
 
 47 
 
 20 
 
 52 
 
 37 
 
 238 
 
 15 
 
 181 
 
 22 
 
 302 
 
 50 to 59 years . 
 
 156 
 
 249 
 
 106 
 
 194 
 
 49 
 
 184 
 
 57 
 
 203 
 
 50 
 
 636 
 
 20 
 
 471 
 
 30 
 
 830 
 
 60 to 69 years. 
 
 244 
 
 678 
 
 201 
 
 618 
 
 104 
 
 679 
 
 97 
 
 563 
 
 43 
 
 1244 
 
 17 
 
 992 
 
 26 
 
 1484 
 
 70 to 79 years. 
 
 224 
 
 1554 
 
 205 
 
 1570 
 
 88 
 
 1572 
 
 117 
 
 1568 
 
 19 
 
 1401 
 
 6 
 
 992 
 
 13 
 
 1731 
 
 80 years and over.. 
 
 92 
 
 2644 
 
 83 
 
 2655 
 
 30 
 
 2671 
 
 53 
 
 2646 
 
 9 
 
 2542 
 
 4 
 
 2985 
 
 5 
 
 2273 
 
 Total . 
 
 820 
 
 112 
 
 647 
 
 104 
 
 296 
 
 96 
 
 351 
 
 111 
 
 173 
 
 159 
 
 67 
 
 126 
 
 106 
 
 191 
 
 * This distribution of deaths does not include the 3 recorded under softening of the 
 brain for this year. 
 
 the lethal force of kidney affections. Not until after 1855 did the rate for 
 kidney disease as a whole equal the rate of 5 in 1920 for renal affections other 
 than Bright’s disease, and as late as 1871-1875 the rate was only 15. By a 
 steady rise the rate increased by 300 per cent during the succeeding 15 years 
 and for the period 1886-1890 was 60. Having advanced from 88 for 1891- 
 1895 to 143 for 1901-1905, during the next 15 years the average rate for 
 Bright’s disease scarcely varied from 170. Since 1901, deaths from acute and 
 chronic nephritis have been recorded separately. From the averaged rates for 
 these two rubrics, it appears that for the first 2 and the last of the 4 quin¬ 
 quennial period the rates for acute Bright’s disease did not vary far from 12, 
 while for the third period they were double this figure. The fluctuations in 
 the rates for chronic nephritis since 1905 have been comparatively slight. 
 Using the data for 1920 for comparison (table 113), it appears that while the 
 rate was about one-half higher in the negro than the white population, there 
 
VARIOUS CHRONIC ORGANIC DISEASES 
 
 46J 
 
 was no considerable difference in the mortality for the two sexes of either race. 
 The influence of age, however, was very marked. For the whole population 
 mortality rates were negligible in the first decade and in the second decade the 
 rates for each category were uniformly relatively low. From the twentieth 
 to the eightieth year the rate for each decade of life was more than double that 
 for the age-period immediately preceding, the actual increase being from 25 
 in the third to 1,741 in the eighth decade. In the age-group 80 and over the 
 mortality was 2,874. While this same ratio of increase obtained for whites, 
 the progress of mortality through the decades of life was somewhat different 
 for negroes, among whom it was not maintained during the seventh and eighth 
 decades. In whites, as between the sexes, the rates were uniformly higher in 
 
 ‘Table 113 .—Number of deaths and rate of death, per 100,000 living inhabitants, from 
 
 nephritis, according to age, color, and sex, for 1920. 
 
 D = death. R = rate. 
 
 
 r T^v4- r. 1 
 
 White. 
 
 Colored. 
 
 
 
 a 1 * 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Age-period. 
 
 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 Under 1 year. 
 
 2 
 
 13 
 
 1 
 
 8 
 
 1 
 
 15 
 
 . . . 
 
 • • • • 
 
 1 
 
 51 
 
 
 
 1 
 
 99 
 
 1 to 4 years. 
 
 1 
 
 2 
 
 1 
 
 2 
 
 • • • 
 
 • • • • 
 
 1 
 
 4 
 
 
 
 
 
 
 
 5 to 9 years. 
 
 1 
 
 2 
 
 1 
 
 2 
 
 1 
 
 4 
 
 
 
 
 
 
 
 
 
 0 to 9 years. 
 
 4 
 
 3 
 
 3 
 
 3 
 
 2 
 
 3 
 
 1 
 
 2 
 
 1 
 
 6 
 
 
 
 1 
 
 12 
 
 10 to 19 years. 
 
 12 
 
 10 
 
 11 
 
 9 
 
 6 
 
 11 
 
 5 
 
 9 
 
 1 
 
 6 
 
 
 
 1 
 
 11 
 
 20 to 29 years. 
 
 36 
 
 25 
 
 22 
 
 18 
 
 11 
 
 19 
 
 11 
 
 18 
 
 14 
 
 54 
 
 10 
 
 82 
 
 4 
 
 29 
 
 30 to 39 years. 
 
 67 
 
 55 
 
 44 
 
 44 
 
 28 
 
 56 
 
 16 
 
 32 
 
 23 
 
 105 
 
 12 
 
 109 
 
 11 
 
 102 
 
 40 to 49 years. 
 
 127 
 
 138 
 
 81 
 
 106 
 
 37 
 
 97 
 
 44 
 
 114 
 
 46 
 
 295 
 
 17 
 
 205 
 
 29 
 
 398 
 
 50 to 59 years. 
 
 225 
 
 360 
 
 162 
 
 296 
 
 90 
 
 337 
 
 72 
 
 257 
 
 63 
 
 802 
 
 34 
 
 801 
 
 29 
 
 803 
 
 60 to 69 years. 
 
 269 
 
 747 
 
 223 
 
 685 
 
 123 
 
 804 
 
 100 
 
 580 
 
 46 
 
 1331 
 
 21 
 
 1226 
 
 25 
 
 1427 
 
 70 to 79 years. 
 
 251 
 
 1741 
 
 226 
 
 1731 
 
 110 
 
 1965 
 
 116 
 
 1555 
 
 25 
 
 1844 
 
 14 
 
 2314 
 
 11 
 
 1465 
 
 80 years and over.. 
 
 100 
 
 2874 
 
 89 
 
 2847 
 
 41 
 
 3651 
 
 48 
 
 2396 
 
 11 
 
 3107 
 
 4 
 
 2935 
 
 7 
 
 3182 
 
 Total . 
 
 1091 
 
 149 
 
 861 
 
 138 
 
 448 
 
 145 
 
 413 
 
 130 
 
 230 
 
 212 
 
 112 
 
 210 
 
 118 
 
 213 
 
 males than in females, except in the fifth decade of life. In negroes, the rates 
 for males were higher than those for females only in the fifth, sixth, and 
 seventh decades and in the age-group 80 years and over. On the whole, the 
 variations in mortality between the sexes in respect of the different age-groups 
 were less marked in the black than in the white race. 
 
 With average rates not over 3 for the 4 quinquennial periods between 1876 
 and 1895, the mortality ascribed to arterial disease (table 110) reached 9 
 between 1896 and 1900, and 22 between 1901 and 1905. Rising slightly to 24 
 for the next 5-year period, the rates advanced to 38 between 1911 and 1915 
 and fell to 25 between 1916 and 1920. Using the year 1920 as a criterion 
 (table 114), it is observed that while the rates were nearly twice as great in 
 whites as in negroes, there was little or no difference in the rates for the two 
 sexes of these races. In regard to age, no deaths were recorded in whites below 
 the fortieth year, and the mortality was slight below the sixtieth year. In 
 negroes, on the other hand, there were no deaths before the sixtieth year of 
 age. The rates were higher for females than for males only in the eighth 
 
462 
 
 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 decade of life among whites. Higher rates for males than for females occurred 
 among negroes in the seventh decade and after the eightieth year. The com¬ 
 paratively low death-rate for the whole population, and the occurrence of 
 recorded deaths only in the high age-ranges, suggest that deaths certified as 
 due to arterio-sclerosis in Baltimore were associated chiefly with the senile 
 type of the disease. It is well established among pathological anatomists that 
 diffuse or general arterio-sclerosis of the Gull and Sutton type is common, 
 especially among white and negro males between the forty-fifth and the 
 sixtieth years. 
 
 The mortality-rates from general dropsy (table 110) followed an entirely 
 different course from those for the other rubrics under consideration. Though 
 there were occasional fluctuations, the course of mortality between 1812-1815 
 and 1916-1920 was generally downward. Rates over 60 were attained in 8 
 quinquennial periods, in 2 of which the rates were over 80. The decline 
 
 Table 114 .—Number of deaths and rate of death, per 100,000 living inhabitants, from 
 arterio-sclerosis, according to age, color, and sex, for 1920. 
 
 D = death. R = rate. 
 
 Age-periocL 
 
 Total. 
 
 White. 
 
 Colored. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 i 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 1 to 39 years. 
 
 
 
 
 
 
 
 
 j 
 
 
 
 
 
 
 
 40 to 49 years. 
 
 2 
 
 2 
 
 2 
 
 3 
 
 1 
 
 3 
 
 1 
 
 3 
 
 
 
 
 
 
 
 50 to 59 years. 
 
 5 
 
 8 
 
 5 
 
 9 
 
 3 
 
 11 
 
 2 
 
 7 
 
 
 
 
 
 
 
 60 to 69 years. 
 
 29 
 
 81 
 
 24 
 
 74 
 
 16 
 
 105 
 
 8 
 
 46 
 
 5 
 
 144 
 
 3 
 
 175 
 
 2 
 
 114 
 
 70 to 79 years. 
 
 40 
 
 278 
 
 37 
 
 283 
 
 10 
 
 179 
 
 27 
 
 362 
 
 3 
 
 221 
 
 1 
 
 165 
 
 2 
 
 266 
 
 80 years and over. 
 
 39 
 
 1121 
 
 37 
 
 1184 
 
 19 
 
 1692 
 
 18 
 
 899 
 
 2 
 
 565 
 
 1 
 
 746 
 
 1 
 
 455 
 
 Total . 
 
 115 
 
 16 
 
 105 
 
 17 
 
 49 
 
 16 
 
 56 
 
 18 
 
 10 
 
 9 
 
 5 
 
 9 
 
 5 
 
 9 
 
 after 1876, during the period in which the increase for the other rubrics was 
 greatest, is very striking. 
 
 In the period under review the mortality-rates from three of these rubrics, 
 heart disease, nephritis, and arterial disease (arterio-sclerosis and apoplexy), 
 have increased. The rate of increase, while not steady and unbroken for any 
 one, has been great—in the case of the heart disease by over 6,000 per cent. 
 The mortality-rate for dropsy, on the other hand, has undergone a decrease, 
 which since 1870 has been notable. In how far are these changes real and 
 dependent upon actual modifications in the lethal force of diseases of these 
 organs? To what degree are they apparent and to be explained by advance¬ 
 ment in medical knowledge, especially in pathology and in methods of pre¬ 
 cision in diagnosis, and by changes in classification of causes of death? It is 
 impossible to answer these questions with exactness, but several lines of 
 inquiry offer promise of partial explanations. 
 
 Owing to the definite objective character of the clinical symptoms in average 
 cases and early knowledge of its pathology, apoplexy was the first of these 
 causes of death in which diagnosis may be expected to have been made with 
 
VARIOUS CHRONIC ORGANIC DISEASES 
 
 463 
 
 comparative readiness and certainty. The classification of deaths from typical 
 apoplectic stroke was never in this period subject to confusion. While it is 
 quite possible that some deaths properly belonging under this rubric may 
 have been classified under paralysis, the course of recorded mortality from 
 that cause (table 117) does not suggest that this was done in any large pro¬ 
 portion of instances. More likely, some deaths in the aged following remotely 
 upon apoplexy may have been classified under senility or under causes un¬ 
 known. The evidence at hand suggests very strongly that the trend of the 
 recorded data concerning apoplexy reflects with a moderate degree of accuracy 
 the actual course of the lethal force of the diseases of the cerebral vessels 
 upon which the clinical picture of this affection is founded. 
 
 While the importance of aneurism and of sclerosis, or atheroma as it was 
 commonly called, of the arteries of certain organs, those of the heart and 
 brain in particular, and the frequent occurrence of pipestem-like thickening 
 with calcification of superficial arteries in the aged had long been recognized, 
 it was not until after the work of Gull and Sutton in 1872 that general 
 arterio-sclerosis gained admission to medical nosology. Its importance as one 
 of the most, or indeed the most, common and serious disease of the vascular 
 system was first called to the attention of the local medical profession in 
 1890 by Osier, who recognized it clinically, and by Welch, Councilman, and 
 the writer, who studied it at autopsy. Ten years elapsed before these teach¬ 
 ings were seriously reflected in the mortality-rate for arterial disease. Owing 
 to the fact that so many of the objective and subjective symptoms of the 
 disease center about the heart, which in so many cases breaks down under its 
 burden, many of the deaths of individuals in whom arterio-sclerosis is the 
 primary affection are returned as due to primary disease of the heart. This 
 was especially the case when heart hypertrophy, of which arterio-sclerosis is 
 the most common cause after the fortieth or fiftieth year, was regarded as a 
 primary disease rather than a compensatory adaptation. On account of the 
 renal disease which usually but not necessarily attends arterio-sclerosis, a not 
 inconsiderable proportion of deaths that should be ascribed to the latter are 
 yet credited by physicians to the former disease. As the great mass of instances 
 of cerebral hemorrhage or apoplexy and of angina pectoris are due to arterio¬ 
 sclerosis, and as many deaths from general arterio-sclerosis have been certified 
 and classified under cardiac and renal disease, it is clear that the official figures 
 for arterio-sclerosis fall far short of actual occurrence. The mortality from 
 general arterio-sclerosis, whatever it was before 1900, was probably hidden 
 partly in renal but chiefly in cardiac diseases. This affection in typical form 
 was very common in 1890, when it was first recognized in Baltimore. All the 
 evidence at hand supports the opinion that it was by no means a new disease, 
 but only a common disease newly recognized. It would appear that there has 
 been no significant change in the rate of its recognition since 1900. It has 
 been pointed out in the discussion of the age distribution of deaths classified 
 under arterial disease that deaths certified as due to arterio-sclerosis by phy¬ 
 sicians must be confined largely to the senile type. 
 
 Until 1895, the mortality figures measure the degree of recognition rather 
 than the lethal force of kidney disease, for even allowing for differences in 
 the age distribution of the population, unless the mortality increased in ratios 
 that stagger the imagination, the picture presented by these figures can not 
 
464 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 truly represent actual occurrence. The mortality-rates for renal disease did 
 not reach 15 until the quinquennium 1871-1875, half a century after Richard 
 Bright’s first contributions to the pathology of the kidney affections identified 
 with his name and a quarter of a century after Charles Frick had impressed 
 upon his Baltimore colleagues the importance of the use of chemical methods, 
 and when Christopher Johnson, sr., was using microscopical methods of uri¬ 
 nary examination. By 1890 there could have been few physicians unfamiliar 
 with the clinical course of Bright’s disease, but, nevertheless, within the next 
 10 years the mortality-rate doubled, and continued to rise until 1906. It may 
 well be that the failure of the rate for nephritis to rise between 1906 and 1920 
 was due to the assignment of some of the deaths which would otherwise have 
 been classified under this rubric to arterio-sclerosis, and that during this 
 period the balance of the rates as between these two rubrics became stabilized. 
 
 While the older physicians were careful observers and possessed many 
 criteria, such as the character of the pulse, shortness of breath, pain in the 
 region of the heart, evidences of engorgement of the lungs, blueness of the skin, 
 and the like, upon which to base diagnosis of heart disease, the use of refined 
 methods is nowhere more necessary for accuracy than in the field of cardiac 
 disease. It was pointed out in another section that previous to 1890 no large 
 proportion of Baltimore physicians had had opportunity for accurate train¬ 
 ing in palpitation, percussion, and auscultation of the chest. The more recently 
 introduced instruments of precision, the blood-pressure gauge and the electro¬ 
 cardiogram, must have tended to augment appreciably the proportion of deaths 
 ascribed to cardiac disease. On the whole, during the past 30 years many 
 events have conspired to increase the mortality-rates for heart and kidney 
 diseases and general arterio-sclerosis by increasing precision in diagnosis. It 
 is evident from the tables that at least some of the increase in the rates for 
 these three rubrics, organic heart disease, arterio-sclerosis, and nephritis, has 
 been at the expense of the rubric dropsy, which has declined as the others have 
 risen. This is not surprising, because the affections included under these 
 rubrics embrace all the pathological states responsible in significant degree 
 for general dropsy. Therefore, while the deaths ascribed to dropsy can not be 
 apportioned correctly among the other three rubrics, it follows that the sum 
 of the rates for the four rubrics must express with some degree of nearness 
 actual observed experience for the group as a whole. When this was done 
 (table 110), the combined rate fell steadily from 82 for 1812-1815 to 41 for 
 1831-1835, and then rose during the following 20 years to 114 for 1851-1855, 
 a rate maintained for 15 years. Between 1866 and 1880, the rate fluctuated 
 between 137 and 145. After 1880, when the rate for dropsy had become 
 insignificant, the rates for this group continued to ascend uninterruptedly, 
 but by unequal steps, to 388 for the period 1916-1920. The relatively slight 
 changes in the combined rate for these affections between 1906 and 1920 was 
 associated with stabilized rates for arterio-sclerosis and nephritis and with 
 ascending rates for cardiac disease. Whatever the explanation may be, the 
 rates for this group, as judged from the officially recorded figures, fell by 
 50 per cent between 1812 and 1835, but by 1850 had surpassed the former high 
 level. When the course of the rates for this group is compared with that of the 
 rates for senility and causes unknown in adults (table 110) in the earlier 
 years, in general the rates for the latter were high or indeed often rising when 
 
VARIOUS CHRONIC ORGANIC DISEASES 
 
 465 
 
 the former were falling or at least low. During the period of increase in pre¬ 
 cision of diagnosis between 1880 and 1905 the rates for senility and for causes 
 unknown fell, while those for the cardio-vascular-renal group rose. Although 
 the assumption that all the deaths classified under the rubrics senility and 
 causes unknown in adults should have been assigned to cardio-vascular-renal 
 diseases is by no means warranted, it is probable that a very large moiety of 
 the number properly belonged under those rubrics. Since 1905, while precision 
 of diagnosis in this group of diseases has probably advanced but slightly, but 
 classification of the certified causes of death has become more exact, the rates 
 for senility and causes unknown have fallen to negligible levels and the mor¬ 
 tality for cardiac, renal, and arterial disease (exclusive of apoplexy) taken 
 together has become more stable (column 5, table 110). It is reasonable to sup¬ 
 pose that some of the increase in the recorded mortality from these diseases 
 is dependent upon changes in the age distribution of the population resulting 
 in a gradual increase in the proportion of persons in the age-groups in which 
 their force of mortality is naturally high. However, rates corrected for age 
 indicate that between 1830 and 1920 for heart disease less than 5 per cent, 
 and for apoplexy less than 30 per cent, of the rise in rates can be explained 
 by this factor. 
 
 When the rates for apoplexy are combined with those for cardiac and renal 
 diseases and for arterio-sclerosis and dropsy (column 7, table 110), until 
 1870 the shape of the curve is very close to that of the total rates for the other 
 numbers of the group without apoplexy (column 5, table 110). After 1870, 
 the ascent in the curve for the former is much steeper and smoother than that 
 for the latter. The sum of the rates for the five rubrics, heart, renal, and 
 arterial disease, dropsy, and apoplexy, must be taken as measuring the course 
 of the lethal force of cardio-vascular-renal affections as indicated by the official 
 records. Thus viewed (column 7, table 110, graph 28), the mortality-rate 
 which stood at 92 between 1812 and 1815 and rose to 109 between 1816 and 
 1820, fell almost unbrokenly during the succeeding 25 years to 73 between 
 1841 and 1845. In the next quinquennium the rate approached closely its 
 previous highest level, and from 1851 to 1865 it varied between 132 and 139. 
 Between 1866 and 1895 the rate more than doubled. By steady progression 
 it rose from 332 for 1896-1900 to 508 for the quinquennium ending in 1920. 
 Thus measured it appears, then, that the recorded mortality from this group 
 of affections increased by over 450 per cent between 1812 and 1815 and 1916 
 and 1920. 
 
 For the years 1918-1920, inclusive, data are available for estimating the 
 influence of race and sex upon mortality from these four rubrics. Bates 
 specific for these attributes are presented in table 115. Taking the rates 
 averaged for the three years, it will be noted that for each rubric except 
 arterio-sclerosis the rates are higher in negroes than in whites, and that among 
 the latter there are no significant differences in the rates for the two sexes 
 in any of the rubrics. Among negroes the rates were significantly higher in 
 males for heart disease and in females for apoplexy. The total averaged rates 
 for the four rubrics taken together were 510 for the whole population, 470 and 
 741 for whites and negroes, 465 and 471 for male and female whites, and 739 
 and 742 for male and female negroes, respectively. 
 
466 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 This extraordinary rise in the rates for this group of diseases in the more 
 than 100 years under review is satisfactorily explained neither by errors of 
 diagnosis and faults of statistical classification, nor by changes in the age and 
 race groupings of the population. It has been found that when all the deaths 
 attributed to senility and causes unknown in adults—the only two rubrics 
 available for hiding in earlier years any considerable proportion of deaths 
 due to the group of cardio-vascular-renal disease now under consideration— 
 are by the most liberal interpretation assigned to the latter group, the balance 
 remains far from equal. Assuming that the changes in the age distribution 
 of the population exerted the same influence upon the rates for nephritis, 
 
 Table 115 .—Number of deaths and rate of death, 'per 100,000 living inhabitants, from organic 
 diseases of the heart, softening of the brain and apoplexy, nephritis, and arteriosclerosis, 
 according to color and sex, for 1918, 1919, and 1920, with their respective averaged rates 
 for the 8-year period 1918-1920. 
 
 D = death. R = rate. 
 
 Disease. 
 
 Year. 
 
 Total. 
 
 White. 
 
 Colored. 
 
 Total- 
 
 Male. 
 
 Fem. 
 
 To'al. 
 
 Male. 
 
 Fem. 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 
 f1918 . 
 
 1533 
 
 248 
 
 1128 
 
 217 
 
 585 
 
 228 
 
 543 
 
 207 
 
 405 
 
 409 
 
 194 
 
 428 
 
 211 
 
 393 
 
 ui game 
 
 1919 . 
 
 1270 
 
 176 
 
 967 
 
 157 
 
 471 
 
 153 
 
 496 
 
 160 
 
 303 
 
 291 
 
 158 
 
 330 
 
 145 
 
 257 
 
 diseases oi 
 
 1920 . 
 
 1366 
 
 186 
 
 1061 
 
 170 
 
 510 
 
 165 
 
 551 
 
 174 
 
 305 
 
 282 
 
 161 
 
 302 
 
 144 
 
 260 
 
 me Heart 
 
 Average . .. 
 
 • • • • 
 
 203 
 
 « • • • 
 
 181 
 
 ... 
 
 182 
 
 • • • 
 
 181 
 
 • • • 
 
 327 
 
 • • • 
 
 354 
 
 • • • 
 
 303 
 
 Softening 
 
 f 1918 . 
 
 835 
 
 135 
 
 652 
 
 126 
 
 302 
 
 118 
 
 350 
 
 134 
 
 183 
 
 185 
 
 69 
 
 152 
 
 114 
 
 212 
 
 of the 
 
 j 1919 . 
 
 838 
 
 116 
 
 676 
 
 110 
 
 316 
 
 103 
 
 360 
 
 116 
 
 162 
 
 155 
 
 60 
 
 125 
 
 102 
 
 181 
 
 brain and 
 
 1920 . 
 
 823 
 
 112 
 
 650 
 
 104 
 
 297 
 
 96 
 
 353 
 
 111 
 
 173 
 
 159 
 
 67 
 
 126 
 
 106 
 
 191 
 
 apoplexy 
 
 Average ... 
 
 .... 
 
 121 
 
 .... 
 
 113 
 
 • • • 
 
 106 
 
 ... 
 
 120 
 
 • • • 
 
 166 
 
 • • • 
 
 134 
 
 • • • 
 
 195 
 
 
 f 1918 . 
 
 1150 
 
 186 
 
 888 
 
 171 
 
 466 
 
 181 
 
 422 
 
 161 
 
 262 
 
 265 
 
 126 
 
 278 
 
 136 
 
 253 
 
 Nephritis 
 
 1919 . 
 
 1137 
 
 158 
 
 903 
 
 146 
 
 434 
 
 141 
 
 469 
 
 151 
 
 234 
 
 224 
 
 107 
 
 224 
 
 127 
 
 225 
 
 1920 . 
 
 1091 
 
 149 
 
 861 
 
 138 
 
 448 
 
 145 
 
 413 
 
 130 
 
 230 
 
 212 
 
 112 
 
 210 
 
 118 
 
 213 
 
 
 Average ... 
 
 « • • • 
 
 164 
 
 .... 
 
 152 
 
 ,.. 
 
 156 
 
 • • • 
 
 148 
 
 • • • 
 
 234 
 
 • • • 
 
 237 
 
 • • • 
 
 230 
 
 
 fl918 . 
 
 169 
 
 27 
 
 152 
 
 29 
 
 82 
 
 32 
 
 70 
 
 27 
 
 17 
 
 17 
 
 10 
 
 22 
 
 7 
 
 13 
 
 Arterio- 
 
 1919 . 
 
 144 
 
 20 
 
 129 
 
 21 
 
 57 
 
 19 
 
 72 
 
 23 
 
 15 
 
 14 
 
 5 
 
 10 
 
 10 
 
 18 
 
 sclerosis 
 
 1920 . 
 
 115 
 
 16 
 
 105 
 
 17 
 
 49 
 
 16 
 
 56 
 
 18 
 
 10 
 
 9 
 
 5 
 
 9 
 
 5 
 
 9 
 
 
 Average ... 
 
 • • • • 
 
 21 
 
 • • • • 
 
 22 
 
 • • • 
 
 22 
 
 ... 
 
 23 
 
 • • • 
 
 14 
 
 • • • 
 
 14 
 
 • • • 
 
 13 
 
 arterio-sclerosis, and dropsy as for heart disease and for apoplexy, a large gap 
 yet remains to be filled. During the period of rising rates, the negro, with his 
 conspicuously higher death-rates from this group of diseases, has steadily 
 decreased in numerical proportion to the white in the population. In regard 
 to the possible influence of sex, there has been no considerable variation in 
 the proportion of males and females in the population. All things measurable 
 considered, the conclusions seems inevitable that since 1870 there has been a 
 progressive but gradual actual increase in the mortality from cardio-vascular- 
 renal disease, independent of changes in race and age composition of the 
 population. 
 
 According to the experience of 1910 and 1920, when rates specific for age 
 may be calculated with a reasonable degree of accuracy, the mortality from 
 
VARIOUS CHRONIC ORGANIC DISEASES 
 
 467 
 
 cardio-vascular-renal disease was limited very largely, though by no means 
 entirely, to individuals of 40 years of age and over. It has been shown that 
 since 1850, at least, this age group of the population has increased very con¬ 
 siderably in its proportional relations to the whole. Therefore, rates calcu¬ 
 lated from the combined mortality figures for all these rubrics in the census 
 years 1850 to 1920, inclusive, on the basis populations in this age-group should 
 be, within a moderate degree of error, specific for age. The results of such a 
 calculation are presented in table 116 and graph 29. Judged by this criterion, 
 admittedly lacking in absolute exactness, there was singularly little change in 
 the rate of mortality from these affections between 1850 and 1870. Between 
 1870 and 1910 the rate ascended by regular steps, with the result that in this 
 period the mortality was nearly doubled; but in 1920 the rate was lower than 
 in 1890 and but little higher than in 1880. In so far as conclusions may be 
 justified from these premises, in which no allowances are made for the infl- 
 ence of such important factors as color and sex, it appears that, while mortality 
 
 Table 116 . —Number of deaths and rate of death, per 100,000 
 living inhabitants over J+0 years of age, from cardio-vas- 
 cular-renal diseases, for the decennia 1830 to 1920, inclu¬ 
 sive,* 
 
 D = death. R = rate. 
 
 Year. 
 
 D 
 
 R 
 
 Year. 
 
 D 
 
 R 
 
 1830 . . 
 
 63 
 
 278 
 
 1880 .. 
 
 737 
 
 958 
 
 1840 .. 
 
 96 
 
 601 
 
 1890 .. 
 
 1184 
 
 1141 
 
 1850 .. 
 
 225 
 
 777 
 
 1900 .. 
 
 1783 
 
 1413 
 
 1860 .. 
 
 285 
 
 712 
 
 1910 .. 
 
 2511 
 
 1656 
 
 1870 .. 
 
 438 
 
 780 
 
 1920 .. 
 
 2225 
 
 1066 
 
 * The number of deaths for each decennium is a 3-year 
 average of that obtaining in the decennial year and in those 
 years immediately preceding and following, except in 1920, when 
 the average is for 1919 and 1920 only. 
 
 from cardio-vascular-renal disease has increased considerably since 1850, the 
 actual increase has been much less than indicated by the crude rates. In fact, 
 when correction is made for age in this in some respects crude fashion, it seems 
 certain that mortality from this group of causes really declined between 1910 
 and 1920 and that the rate was actually lower in 1920 than in 1890. 
 
 Further consideration of this table brings to light two facts that demand 
 explanation. The rates were much higher in 1850 than in 1860 and consid¬ 
 erably lower in 1920 than in 1890, although they rose sharply between 1840 
 and 1850 and steadily between 1890 and 1910. If these mortality-rates possess 
 any significant basis of trustworthiness, some more reasonable explanation 
 than changes in statistical classification is necessary. Here is a compound 
 group of chronic organic diseases whose mortality-rates reasonably specific 
 for age run a course similar to those of some specific infectious disease. In 
 this peculiarity lies a plausible partial solution of the mystery. Many statis¬ 
 ticians, of whom Bertillon (64) and Pearl (65) are to be especially men¬ 
 tioned in this connection, have observed that one of the most conspicuous 
 immediate effects of epidemic influenza is to raise the mortality from the group 
 
468 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 of causes here grouped under cardiovascular affections. The ascent in the 
 rate for 1850 corresponds to the influenza epidemic of 1849-1850, which appar¬ 
 ently died out at once, without becoming endemic.. Its effects, whatever their 
 other characters, were sharp and transient, and therefore made no permanent 
 impression. The impact of the pandemic of 1890 was associated with a sharp 
 rise in the rate for cardio-vascular-renal diseases, which was, however, not 
 transient, but lasting. The mortality continued to rise through the next two 
 decennia and well into the third (through 1918). But, as lias been shown in 
 the discussion of influenza, this disease also changed its habit and, instead of 
 disappearing, settled into endemicity. It may well be that in each year 
 between 1891 and 1917 endemic influenza killed off a certain proportion of 
 the susceptible weaklings among the cardio-vascular-renally afflicted popula¬ 
 tion, and in the pandemic of 1918 this crop was harvested in even greater 
 numbers than usual. The sharp decline in the rate for cardio-vascular-renal 
 affections during the three following years (reflected in the rate for 1920 
 in table 101), while influenza continued endemic, would be explained for the 
 same reasons by the unusually heavy losses in 1918. 
 
 The chief objections to this argument are: (1) The mortality from these 
 affections rose between 1861 and 1880, in a period without influenza, and 
 (2) if endemic influenza operated so effectively for the 27 years after 1890, 
 long before the expiration of this time it should have so seriously depleted 
 its store of possible victims, that the rate for cardio-vascular-renal diseases 
 should have fallen in comparatively few years to much lower levels. The most 
 ready escape from this dilemma is to assume that a very large part in the 
 causation of this disease-group, or at least of its most prominent member, 
 heart disease, is borne by the common communicable diseases (including 
 influenza), many of which were at this acme in the seventh, eighth, and ninth 
 decennia of the last century, and that since their decline endemic influenza 
 has in a large measure taken on.this role. However this may be, it seems cer¬ 
 tain that the death-rate of cardio-vascular-renal disease has been determined, 
 at times at least, in some significant measure by influenza. 
 
 The general biological implications of the effects of the febrile diseases upon 
 the course of mortality from this set of causes will be considered further 
 under the discussion changes of the death-rate from all causes. 
 
Chapter XV. —Diseases of the Central Nervous 
 System and Liver; Diabetes; Alcoholism. 
 
 (Tables 117 to 119.) 
 
 CHRONIC DISEASES OF THE CENTRAL NERVOUS SYSTEM. 
 
 To the rubric palsy, later changed to paralysis in 1874 and to paralysis 
 without specified cause in 1899, a gradually increasing number of deaths were 
 credited each year from 1812 to 1892 (table 117). Since the latter date, with 
 the gradual increase in the proportional allotment of deaths from diseases of 
 the nervous system to other rubrics, this rubric declined in relative impor¬ 
 tance, and, with the revision of the international classification effective in 
 1910, as rubric 66, sank into comparative obscurity. 
 
 In order of their entrance into the statistical nosology, there appeared epi¬ 
 lepsy in 1827, chorea in 1837, locomotor ataxia in 1878, general paralysis of 
 the insane in 1899, other diseases of the spinal cord in 1902, and other diseases 
 of the nervous system in 1910. It is to be presumed that, until and unless 
 specifically assigned to these other rubrics, deaths due to primary diseases of 
 the nervous system associated with paralysis (and this excludes of course 
 apoplexy, hemorrhage, congestion, and softening or mechanical injury of the 
 brain, all considered elsewhere) were classified under the original rubric palsy 
 or its successor, rubric 66. 
 
 The mortality-rates for these rubrics, separate and combined, as averaged 
 for quinquennial periods, are presented in table 118. As it is not possible to 
 follow the deaths from insanity with any certainty, they have been left out of 
 consideration. It will be noted that while the rates for chorea varied from 
 time to time, this affection has not been an important cause of death. The 
 rates for epilepsy assume importance only after 1870, and since this date they 
 have not risen above 4 nor fallen below 2. Somewhat lower rates have pre¬ 
 vailed for locomotor ataxia (1 to 3) since 1880. This affection reached 
 its highest recorded mortality level in 1901-1910. The rate for general paraly¬ 
 sis rose from 3 in 1901-1905 to 5 in 1906-1915, but during the last quinquen¬ 
 nium fell to 3. The decrease in the rates for both these two forms of syphilis 
 of the nervous system during the period 1916-1920 was due to the fact that 
 owing to a change in custom of classification of deaths an increasingly large 
 proportion of deaths ascribed to them have been classified under syphilis. 
 During the 10-year period 1911-1920, the new rubric, other diseases of the 
 nervous system (number 74), has come into prominence with rates of 5 and 
 6 during the two quinquennia. 
 
 It will be observed that, for practical purposes, the old rubric palsy or 
 paralysis unspecified held the ground almost unchallenged during the nine¬ 
 teenth century, and that only since 1900, with the full differentiation of other 
 rubrics, has it receded in importance. 
 
 Considering this group of affections of the nervous system as a whole, the 
 quinquennial rates rose from 15 for 1812-1815 to 21 during the following 
 10 years. Falling during a period of 20 years after 1825 and reaching the 
 
 469 
 
Table 117. — Number of deaths and rate of death, per 100,000 living inhabitants, from alcoholism, chronic diseases of the central nervous system, 
 
 diseases of the liver and biliary tract, and diabetes, from 1812 to 1920, inclusive. 
 
 470 
 
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Table 117. — Number of deaths and rate of death, per 100,000 living inhab itants, froin alcoholism, chronic diseases of the central nervous system, 
 
 diseases of the liver and biliary tract,and diabetes, from 1812 to 1920, inclusive. —Continued. 
 
 472 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 
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VARIOUS CHRONIC ORGANIC DISEASES 
 
 473 
 
 level of 13 for the quinquennium 1841-1845, the rate rose to 22 in 1846- 
 1850, and remained near this level until 1860. By gradual steps the averaged 
 rate ascended during the next 35 years, and attained its highest level, 58 in 
 1891-1895. From this level, during the next three quinquennia, the rate 
 declined somewhat gradually to 44 in 1906-1910. The rate fell to 36 in 1911— 
 1915 and to 21 in 1916-1920. The very distinct rise between 1860 and 1895 
 in the mortality-rates for paralysis is difficult to explain. It is not possible 
 
 Table 118 .—Average rate of death, 'per 100,000 living inhabitants, by 5-year periods, 
 from alcoholism, chronic diseases of the central nervous system, diseases of the 
 liver and biliary tract, and diabetes, from 1812 to 1920, inclusive. 
 
 Periods. 
 
 Alcoholism. 
 
 Chronic diseases of the 
 
 central nervous system. 
 
 Diseases 
 of liver 
 and biliary 
 tract. 
 
 i 
 
 Diabetes. 
 
 Chorea- 
 
 Epilepsy. 
 
 Locomotor ataxia. 
 
 Other diseases of 
 spinal cord- 
 
 General paralysis. 
 
 Other diseases of 
 nervous system. 
 
 Paralysis unspe¬ 
 
 cified* 
 
 Total. 
 
 Cirrhosis of liver. 
 
 Total. 
 
 1812-15 . 
 
 
 .... 
 
 
 
 .... 
 
 
 
 15 
 
 15 
 
 
 12 
 
 
 1816-20 . 
 
 53 
 
 .... 
 
 
 
 
 .... 
 
 
 21 
 
 21 
 
 
 16 
 
 • • • • 
 
 1821-25 . 
 
 51 
 
 • • * • 
 
 
 
 .... 
 
 
 
 21 
 
 21 
 
 
 41 
 
 • • • • 
 
 1826-30 . 
 
 28 
 
 • • • • 
 
 
 
 
 
 
 16 
 
 17 
 
 
 32 
 
 • • • • 
 
 1831-35 . 
 
 39 
 
 • • • • 
 
 
 
 
 
 
 13 
 
 13 
 
 
 21 
 
 • • • • 
 
 1836-40 . 
 
 35 
 
 0.53 
 
 .... 
 
 .... 
 
 
 
 
 14 
 
 15 
 
 
 14 
 
 • • • • 
 
 1841-45 . 
 
 15 
 
 0.16 
 
 
 
 
 
 
 12 
 
 13 
 
 
 10 
 
 • • • • 
 
 1846-50 . 
 
 17 
 
 • • • • 
 
 . 
 
 
 
 
 
 22 
 
 22 
 
 
 5 
 
 
 1851-55 . 
 
 18 
 
 0.12 
 
 
 
 
 
 
 22 
 
 22 
 
 
 13 
 
 1 
 
 1856-60 . 
 
 14 
 
 0.10 
 
 
 
 
 
 
 23 
 
 23 
 
 
 10 
 
 
 1861-65 . 
 
 8 
 
 0.35 
 
 
 
 
 
 
 28 
 
 29 
 
 
 9 
 
 • • • • 
 
 1866-70 . 
 
 2 
 
 0.08 
 
 1 
 
 
 .... 
 
 .... 
 
 
 33 
 
 34 
 
 
 9 
 
 • • • • 
 
 1871-75 . 
 
 7 
 
 0.48 
 
 3 
 
 
 
 .... 
 
 .... 
 
 38 
 
 41 
 
 
 14 
 
 1 
 
 1876-80 . 
 
 9 
 
 0.32 
 
 4 
 
 0.36 
 
 
 .... 
 
 
 38 
 
 43 
 
 8 
 
 20 
 
 2 
 
 1881-85 . 
 
 11 
 
 0.33 
 
 4 
 
 1 
 
 
 
 
 45 
 
 50 
 
 10 
 
 23 
 
 3 
 
 1886-90 . 
 
 9 
 
 0.50 
 
 4 
 
 1 
 
 
 
 
 47 
 
 52 
 
 12 
 
 23 
 
 4 
 
 1891-95 . 
 
 7 
 
 0.21 
 
 3 
 
 2 
 
 
 
 
 52 
 
 58 
 
 12 
 
 22 
 
 7 
 
 1896-1900 . 
 
 6 
 
 0.44 
 
 2 
 
 2 
 
 
 1 
 
 
 42 
 
 47 
 
 12 
 
 22 
 
 8 
 
 1901-05 . 
 
 8 
 
 0.26 
 
 3 
 
 3 
 
 4 
 
 3 
 
 
 31 
 
 45 
 
 13 
 
 23 
 
 10 
 
 1906-10 . 
 
 9 
 
 0.21 
 
 3 
 
 3 
 
 5 
 
 jr 
 
 0 
 
 1 
 
 27 
 
 44 
 
 13 
 
 23 
 
 13 
 
 1911-15 . 
 
 8 
 
 0.24 
 
 3 
 
 2 
 
 5 
 
 4 
 
 5 
 
 18 
 
 36 
 
 14 
 
 21 
 
 17 
 
 1916-20 . 
 
 4 
 
 0.12 
 
 2 
 
 1 
 
 4 
 
 3 
 
 6 
 
 5 
 
 21 
 
 11 
 
 19 
 
 20 
 
 to arrive at a completely satisfactory explanation for the steady rise in the 
 mortality-rate for paralysis in the period before the rubrics locomotor ataxia, 
 general paralysis (of the insane), and other diseases of the spinal cord and 
 of the nervous system assumed importance. This ascent in the rate may have 
 been due in some measure to the possible inclusion of deaths that should have 
 been classified under congestion, hemorrhage and softening of the brain, and 
 insanity, and to a considerable increase in the prevalence of syphilis or of 
 some other prominent cause or causes of chronic disease of the central nervous 
 system. The decline in the rates for the rubric (paralysis, cause unspecified) 
 since 1896 is accounted for partly by the establishment of the other rubrics 
 to which deaths formerly allotted to it were assigned, and partly to an actual 
 decrease in the deaths from diseases of this group. Similarly, the marked 
 decline in the total rate since 1896, may be attributed to more careful classi- 
 
474 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 fication of deaths, to more general and adequate treatment of syphilis, and to 
 modifications in the death-rates from other diseases, which have claimed in 
 more recent years individuals who in former years would have fallen victims 
 to chronic disorders of the nervous system. It appears to be clear that to no 
 one tangible factor can be credited the explanation of the course of the 
 mortality-rates of this group of diseases as based upon officially recorded 
 deaths during the more than 100 years under review. It will be noted that 
 the averaged rates between 1816 and 1825, 1846 and 1860, were at the same 
 general level (21) obtaining in 1916-1920, when great care was exercised in 
 the accurate classification of deaths. 
 
 Rates specific for age and color for 1920 are given in table 119. In all cate¬ 
 gories, the mortality was light in the early years of life and increased with 
 advancing age. In negroes, no deaths occurred in the first two decades of life, 
 and in every age-group, except 80 years and over, the mortality was decidedly 
 less than among whites. For all ages, the rate for whites was double that 
 for negroes. 
 
 Since 1875, at least, this group of diseases of the nervous system has been 
 studied intensively in Baltimore, first by F. T. Miles, and later by George 
 Preston, H. J. Berkley, William Osier, H. M. Thomas, and others, from whom 
 the general practitioner has had large opportunity to acquaint himself with 
 their recognition. 
 
 DISEASES OF THE LIVER. 
 
 Under one heading or another, deaths from affections of the liver (table 
 117) may be followed continuously since 1812. Jaundice persisted as a sep¬ 
 arate rubric from 1812 to 1898. To inflammation of the liver deaths were 
 attributed in most years between 1814 and 1897. Other rubrics were liver 
 complaint, from 1820 to 1874; liver abscess, in 1821 and 1822 and from 1878 
 to 1898; cirrhosis, since 1875; acute yellow atrophy and gall stones, since 
 1878; and other diseases of the liver since 1899. The sum of these represents 
 the number of deaths attributed to disease of the liver, cancer excepted. For 
 various reasons, cirrhosis of the liver is the only member of the group whose 
 course it is worth while to follow separately. There is ample reason to con¬ 
 clude that, in the earlier years at least, the officially recorded mortality from 
 liver disease has fallen short of actual occurrence. In table 118 the course 
 of the force of recorded mortality from diseases of the liver as a group and 
 for cirrhosis separately may be followed from rates averaged for quinquennial 
 periods. It will be observed that the rates for the total rose from 12, for 1812- 
 1815, to 16 during the succeeding 5 years, and ascended abruptly to 41, the 
 highest level attained* in 1821-1825. During the next 25 years the rate steadily 
 and gradually declined to 5 during the quinquennium 1846-1850. Between 
 1851 and 1875 the averaged rate did not exceed 14 nor fall below 9. Coinci¬ 
 dent with the appearance of cirrhosis of the liver in the statistical classifica¬ 
 tion in 1875, the rate jumped from 14 for 1870-1875 to 20 for 1876-1880. 
 From 1881 there was remarkably little change in the rate. In the 8 quinquen¬ 
 nia rates of 23 obtained in 4, 22 in 2, and 21 and 19 in one each. Similarly, the 
 rate for cirrhosis of the liver varied within narrow limits during this period. 
 Starting from 10 for 1881-1885 and remaining at 12 from 1886 to 1900, and 
 at 13 from 1901 to 1910, the averaged rate rose to 14 in 1911-1915, to fall 
 to 11 in 1916-1920. The stability of the rate for this affection during the 
 40 years is striking. 
 
VARIOUS CHRONIC ORGANIC DISEASES 
 
 475 
 
 It is evident that from 1876 to 1885 somewhat less and after 1886 some¬ 
 what more than half the deaths recorded as caused by disease of the liver and 
 its ducts were contributed by cirrhosis. It w'ould seem that in the earlier years 
 this affection, when recognized, was classified largely under liver complaint 
 and inflammation of the liver, and that before its establishment as a separate 
 rubric it must have been either of less common occurrence than later, was 
 classified elsewhere, or was frequently unrecognized. It appears from table 
 119 in which are given the rates for age and color for the year 1920, there is 
 but little difference in mortality as between whites and negroes. For whites, 
 with an insignificant mortality before the fortieth year, the rate advances 
 steadily to its highest level in the age-period 80 years and over. Among 
 negroes there were no deaths before the fortieth and after the seventieth years 
 of age, and the highest rate occurred in the seventh decade of life. 
 
 DIABETES. 
 
 This long-known disease was not recognized in the local statistical nosology 
 until 1847, when it was credited with 1 death (table 117). It appeared again 
 
 Table 119. —Number of deaths and rate of death, per 100,000 living inhabitants, from chronic 
 diseases of the central nervous system, cirrhosis of the liver, and diabetes, according to 
 age and color, for 1920. 
 
 D — death. R = rate. 
 
 Age-periods. 
 
 Diseases of central nervous 
 system. 
 
 Cirrhosis of liver. 
 
 Diabetes. 
 
 Total. 
 
 White. 
 
 Colored. 
 
 Total. 
 
 White. 
 
 Colored- 
 
 Total. 
 
 White. 
 
 Colored. 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 Under 1 year.... 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1 to 4 years.... 
 
 i 
 
 2 
 
 1 
 
 2 
 
 
 
 
 
 
 
 
 
 1 
 
 2 
 
 1 
 
 2 
 
 
 
 5 to 9 years.... 
 
 3 
 
 5 
 
 3 
 
 5 
 
 
 
 
 
 
 
 
 
 1 
 
 2 
 
 1 
 
 2 
 
 • • 
 
 
 0 to 9 years.... 
 
 4 
 
 3 
 
 4 
 
 3 
 
 
 
 
 
 
 
 
 
 2 
 
 1 
 
 2 
 
 2 
 
 • • 
 
 
 10 to 19 years.... 
 
 6 
 
 5 
 
 6 
 
 6 
 
 
 
 
 
 
 
 
 
 2 
 
 2 
 
 2 
 
 2 
 
 • • 
 
 
 20 to 29 years.... 
 
 12 
 
 8 
 
 10 
 
 8 
 
 2 
 
 8 
 
 1 
 
 1 
 
 1 
 
 1 
 
 
 
 10 
 
 7 
 
 10 
 
 8 
 
 # # 
 
 
 30 to 39 years.... 
 
 13 
 
 11 
 
 12 
 
 12 
 
 1 
 
 5 
 
 2 
 
 2 
 
 2 
 
 2 
 
 
 
 7 
 
 6 
 
 5 
 
 5 
 
 2 
 
 9 
 
 40 to 49 years.... 
 
 18 
 
 19 
 
 17 
 
 22 
 
 1 
 
 6 
 
 10‘ 
 
 11 
 
 8 
 
 10 
 
 2 
 
 13 
 
 20 
 
 22 
 
 14 
 
 18 
 
 6 
 
 39 
 
 50 to 59 years.... 
 
 18 
 
 29 
 
 17 
 
 31 
 
 1 
 
 13 
 
 12 
 
 19 
 
 9 
 
 16 
 
 3 
 
 38 
 
 40 
 
 64 
 
 36 
 
 66 
 
 4 
 
 51 
 
 60 to 69 years.... 
 
 17 
 
 47 
 
 15 
 
 46 
 
 2 
 
 58 
 
 18 
 
 50 
 
 16 
 
 49 
 
 2 
 
 58 
 
 50 
 
 139 
 
 45 
 
 138 
 
 5 
 
 145 
 
 70 to 79 years.... 
 
 19 
 
 132 
 
 18 
 
 138 
 
 1 
 
 74 
 
 8 
 
 56 
 
 8 
 
 61 
 
 
 • * 
 
 21 
 
 146 
 
 20 
 
 153 
 
 1 
 
 74 
 
 80 years and over 
 
 8 
 
 230 
 
 7 
 
 224 
 
 1 
 
 282 
 
 2 
 
 57 
 
 2 
 
 64 
 
 
 
 3 
 
 86 
 
 3 
 
 96 
 
 • • 
 
 • • • 
 
 Total . 
 
 115 
 
 16 
 
 106 
 
 17 
 
 9 
 
 8 
 
 53 
 
 7 
 
 46 
 
 7 
 
 7 
 
 6 
 
 155 
 
 , 
 
 21 
 
 137 
 
 22 
 
 18 
 
 17 
 
 in 1851 and 1852, with 2 and 1 deaths, respectively, and in 1854 with 8 deaths. 
 After appearing again in 1859, 1868, and 1870 with 1 death in each year, 
 this disease took a permanent place in the mortality records in 1873. The rates 
 averaged for 5-year periods are given in table 118. As determined by recorded 
 deaths, the force of mortality of diabetes has risen by very gradual steps from 
 an insignificant level (rate of 1) in 1871-1875 to one of considerable impor¬ 
 tance (rate of 20) by 1916-1920. By 1906-1910 its mortality-rate was equal 
 to and by 1916-1920 was double that for cirrhosis of the liver. While some 
 of this increase of importance of diabetes as a cause of death may be only appar¬ 
 ent, and explainable by better medical diagnosis and more careful classification, 
 there is little doubt that the larger part is real. 
 
 The influence of race and age upon the mortality from diabetes in 1920 is 
 shown in table 119. The rate was 29 per cent greater in whites than in 
 31 
 
476 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 negroes. For the whole population, the rate, which was only 1 in the first, 2 
 in the second, and 7 and 6 in the third and fourth decades, respectively, 
 increased markedly in each succeeding decade until the eightieth year of life, 
 after which there was a considerable fall. Among whites the mortality fol¬ 
 lowed the same general course with the highest rates in the eighth decade. 
 Among negroes there were no deaths earlier than the thirtieth year, and thn 
 highest rate occurred in the seventh decade of life. 
 
 ALCOHOLISM. 
 
 In the statistical records deaths have been attributed to alcoholism in each 
 year since 1818. Deaths from this cause were classified under intemperance 
 from 1818 to 1898, under delirium tremens from 1844 to 1898, and under 
 alcoholism, acute and chronic (rubric 56) from 1899. Annual mortality-rates 
 for these rubrics separate and combined, are given in table 117. It will be 
 observed that for this cause of death intemperance was the sole rubric during 
 the period of highest mortality and remained by far the most important rubric 
 until its disappearance in 1899, and that, in consequence, during the 55 years 
 of its presence in the statistical tables, to delirium tremens was ascribed but 
 a small proportion of the total mortality from alcoholism. Deferring for the 
 moment consideration of all questions in regard to their accuracy and taking 
 the recorded figures at their face value in measuring the mortality from alco¬ 
 holism, two features stand out prominently; first, the wide variations between 
 the extremes of the annual rates, from 83 in 1819 to 1 in 1867 and in 1920, 
 and second, the occurrence of several distinct waves, each extending over a 
 considerable series of years and, with one exception, of progressively decreas¬ 
 ing intensity. The first and highest wave, beginning with a rate of 26 in 1818 
 and reaching its peak with a rate of 83 in 1819, declined somewhat irregularly 
 to the comparatively low level of 15 in 1828. The second wave, with its peak- 
 rate of 51 in 1831, ended in 1844 with a rate of 8. The third wave, extending 
 from 1845 to 1855, reached its highest point in 1849 and 1852 with a rate of 
 24 and fell to 9 in 1855. The fourth wave, with unusually low rates, lasted 
 from 1856 to 1867. The fifth wave, long and irregular, reached its peak in 
 1875 with a rate of 14 and receded to its low point with a rate of 3 by 1897. 
 In the last wave, which attained its highest level with a rate of 11 in 1905 and 
 1906, the decline was gradual though irregular until 1917, after which the 
 descent was abrupt to a rate of 1 in 1920. 
 
 The progressively decreasing intensity of these waves of recorded mortality 
 from alcoholism is well illustrated by the rates as averaged for 5-year periods 
 (table 118). From an average height of over 50 up to 1825, by 1856-1860 
 the rate had fallen to 14, and from this time on was, with the exception of 1 
 quinquennial period, always under 10. Long before prohibition, the mortality 
 officially ascribed to alcoholism had become almost negligible. Data for a com¬ 
 prehensive study of the relation of age, sex, and race to the mortality from 
 alcoholism are lacking. 
 
 Unfortunately, there are no definite criteria for judging the degree of 
 accuracy with which the recorded data represent the true lethal force of alco¬ 
 holism. It is reasonable to suppose that, on account of the opprobrium attached 
 to certain extreme types of over-indulgence in alcohol, for decedents of a 
 
VARIOUS CHRONIC ORGANIC DISEASES 
 
 477 
 
 certain degree of social prominence, in many instances some other cause of 
 death was reported, while for the relatively obscure the bald truth was stated. 
 It may well be that in later years many deaths, which in earlier times and 
 before the development of knowledge of pathological anatomy and patho¬ 
 genesis would have been credited to alcoholism, were classified under chronic 
 affections of particular organs, such as the heart, arteries, liver, kidneys, and 
 nervous system, in the causation of which, for reasons more or less convinc¬ 
 ing, alcohol has been assigned a prominent part. The course of the annual 
 rates during the last 60 years, when a rate of 10 has rarely been exceeded, 
 suggests very strongly that some at least of the decrease in the recorded mor¬ 
 tality is to be explained by changes in medical and statistical nosology result¬ 
 ing in crediting to alcoholism only those deaths occurring in delirium tremens 
 or other pathological states indicative of acute or at least of actively progressive 
 alcoholic poisoning. The relatively great decline in the rate, after 1918, which 
 followed so abruptly upon the administrative interference with sale of alcohol 
 supports this view, for had it at this time been the custom to classify under this 
 rubric any large proportion of the deaths remotely due to alcohol, the fall in 
 the rate could hardly have been so abrupt. On the other hand, it is well 
 established that in earlier times ardent spirits were consumed with much 
 greater constancy and liberality than in recent years. The partiality for strong 
 drink of men connected with shipping is well-known, and the rise and fall in 
 the mortality-rates from alcoholism in the period under review corresponds 
 very closely with the growth and decline of the shipping trade. 
 
N * ku. y -i ***mM - 
 
PART VII.—MISCELLANEOUS CAUSES OF DEATH. 
 
 Chapter XVI. —Violence. 
 
 (Tables 120 to 123, graphs 30 to 32.) 
 
 For convenience, under this heading will be discussed deaths resulting 
 directly or indirectly from man’s acts. These may be divided into two general 
 classes, accordingly as the actions are intentional or unintentional. Under 
 the former class fall deaths from homicide and suicide, and to the latter class 
 belong deaths in the broad sense accidentally caused by drowning, poison, 
 fire, gases, weapons, falls, injuries by machines, vehicles, animals, and elec¬ 
 tricity. In either case, death may be the result of the intentional or of the 
 unintentional acts of the victim himself or of other persons. It is to be recog¬ 
 nized that to a very considerable degree the fatalities under both these cate¬ 
 gories are dependent upon a wide variety of conditions inherent in the cir¬ 
 cumstances in which the victims are situated in particular periods of life and 
 of the city’s history. Among the most important of these are age, occupation, 
 location, and the character and degree of the moral, political, mechanical, 
 industrial, and financial development. There can be little doubt that race 
 stock has exerted a determining influence. In illustration, a few pertinent 
 examples of the facts upon which these generalizations are based may be 
 cited here. Homicides have been unusually frequent in times of political con¬ 
 tention, and suicides have often increased in periods of financial depression 
 and with the decrease in the proportion of negroes and the relative increase 
 of certain other elements in the population. Drownings have become rela¬ 
 tively fewer with the decline of the sailing ship and of the indulgence in 
 aquatic sports with the gradual removal of the residential section from prox¬ 
 imity to the water-front. The incidence as a cause of accidental death of 
 burns, occurring very largely in young children, was influenced unfavorably 
 by the use of open fire-places and coal-oil and gas stoves and favorably by the 
 introduction of coal furnaces. Deaths from machinery accidents have varied 
 with the extension of the use of machinery and perhaps with practical legisla¬ 
 tion. Fatalities from vehicular accidents have greatly increased with the 
 growth of railway service, the introduction of electric power for street rail¬ 
 ways, and particularly of late years with the development of the automobile. 
 Since a large proportion of the deaths classified under accidental falls and 
 fractures occur in the aged, the relative number of deaths attributable to these 
 causes is directly influenced by changes in the ratio of those of advanced age 
 in the population. 
 
 Mortality data for this group as a whole and for homicide, suicide, drown¬ 
 ing, and other accidents for the years 1812 to 1920, inclusive, are given in 
 table 120, graph 30. It will be noted that deaths ascribed to starvation, to 
 excess of heat and cold, and to lightning are not included. Though the rates 
 often fluctuate considerably, not only from year to year, but from one period to 
 another, this group as a whole has been continuously a major cause of death. 
 
 479 
 
480 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 Table 120 .—Number of deaths and rate of death, per 100,000 living inhabitants, by 
 violence, and the percentage of deaths by violence of total deaths from 1812 to 
 1920, inclusive. 
 
 D = death. R = rate. 
 
 Year. 
 
 Homicides and suicides- 
 
 Accidents. 
 
 Total. 
 
 Percentage 
 to total 
 deaths. 
 
 Homi¬ 
 
 cides. 
 
 l 
 
 Suicides. 
 
 Total. 
 
 Drown. 
 
 ings. 
 
 Other ac¬ 
 cidents. 
 
 Total. 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 1812 . 
 
 8 
 
 20 
 
 2 
 
 5 
 
 10 
 
 24 
 
 28 
 
 68 
 
 19 
 
 46 
 
 47 
 
 115 
 
 57 
 
 139 
 
 5 
 
 1813 . 
 
 1 
 
 2 
 
 1 
 
 2 
 
 2 
 
 5 
 
 27 
 
 63 
 
 31 
 
 72 
 
 58 
 
 136 
 
 60 
 
 140 
 
 5 
 
 1814 . 
 
 2 
 
 4 
 
 1 
 
 2 
 
 3 
 
 7 
 
 12 
 
 27 
 
 15 
 
 34 
 
 27 
 
 60 
 
 30 
 
 67 
 
 3 
 
 1815 . 
 
 2 
 
 4 
 
 4 
 
 9 
 
 6 
 
 13 
 
 23 
 
 49 
 
 22 
 
 47 
 
 45 
 
 96 
 
 51 
 
 109 
 
 4 
 
 1816 . 
 
 2 
 
 4 
 
 1 
 
 2 
 
 3 
 
 6 
 
 20 
 
 41 
 
 27 
 
 55 
 
 47 
 
 96 
 
 50 
 
 102 
 
 4 
 
 1817 . 
 
 3 
 
 6 
 
 5 
 
 10 
 
 8 
 
 16 
 
 38 
 
 75 
 
 36 
 
 71 
 
 74 
 
 145 
 
 82 
 
 161 
 
 6 
 
 1818 . 
 
 3 
 
 6 
 
 9 
 
 17 
 
 12 
 
 23 
 
 27 
 
 51 
 
 26 
 
 49 
 
 53 
 
 100 
 
 65 
 
 122 
 
 4 
 
 1819 . 
 
 7 
 
 13 
 
 3 
 
 5 
 
 10 
 
 18 
 
 31 
 
 56 
 
 19 
 
 34 
 
 50 
 
 90 
 
 60 
 
 108 
 
 3 
 
 1820 . 
 
 4 
 
 7 
 
 4 
 
 7 
 
 8 
 
 14 
 
 20 
 
 35 
 
 17 
 
 29 
 
 37 
 
 64 
 
 45 
 
 78 
 
 3 
 
 1821 . 
 
 6 
 
 10 
 
 2 
 
 3 
 
 8 
 
 13 
 
 30 
 
 50 
 
 33 
 
 55 
 
 63 
 
 104 
 
 71 
 
 118 
 
 4 
 
 1822 . 
 
 5 
 
 8 
 
 3 
 
 5 
 
 8 
 
 13 
 
 16 
 
 25 
 
 52 
 
 83 
 
 68 
 
 108 
 
 76 
 
 121 
 
 3 
 
 1823 . 
 
 5 
 
 8 
 
 5 
 
 8 
 
 10 
 
 15 
 
 41 
 
 63 
 
 29 
 
 44 
 
 70 
 
 107 
 
 80 
 
 122 
 
 4 
 
 1824 . 
 
 3 
 
 4 
 
 5 
 
 7 
 
 8 
 
 12 
 
 27 
 
 40 
 
 24 
 
 35 
 
 51 
 
 75 
 
 59 
 
 87 
 
 4 
 
 1825 . 
 
 4 
 
 6 
 
 7 
 
 10 
 
 11 
 
 16 
 
 26 
 
 37 
 
 14 
 
 20 
 
 40 
 
 56 
 
 51 
 
 72 
 
 4 
 
 1826 . 
 
 5 
 
 7 
 
 4 
 
 5 
 
 9 
 
 12 
 
 29 
 
 39 
 
 44 
 
 60 
 
 73 
 
 99 
 
 82 
 
 111 
 
 4 
 
 1827 . 
 
 8 
 
 10 
 
 4 
 
 5 
 
 12 
 
 16 
 
 26 
 
 34 
 
 29 
 
 38 
 
 55 
 
 72 
 
 67 
 
 87 
 
 5 
 
 1828 . 
 
 1 
 
 1 
 
 5 
 
 6 
 
 6 
 
 8 
 
 27 
 
 34 
 
 35 
 
 44 
 
 62 
 
 78 
 
 68 
 
 86 
 
 4 
 
 1829 . 
 
 2 
 
 2 
 
 9 
 
 11 
 
 11 
 
 13 
 
 38 
 
 46 
 
 41 
 
 50 
 
 79 
 
 96 
 
 90 
 
 109 
 
 5 
 
 1830 . 
 
 3 
 
 4 
 
 5 
 
 6 
 
 8 
 
 9 
 
 44 
 
 51 
 
 33 
 
 39 
 
 77 
 
 90 
 
 85 
 
 99 
 
 4 
 
 1831 . 
 
 • • • 
 
 % • • 
 
 6 
 
 7 
 
 6 
 
 7 
 
 29 
 
 33 
 
 44 
 
 50 
 
 73 
 
 82 
 
 79 
 
 89 
 
 4 
 
 1832 . 
 
 5 
 
 5 
 
 5 
 
 5 
 
 10 
 
 11 
 
 23 
 
 25 
 
 36 
 
 39 
 
 59 
 
 64 
 
 69 
 
 75 
 
 2 
 
 1833 . 
 
 8 
 
 8 
 
 7 
 
 7 
 
 15 
 
 16 
 
 28 
 
 29 
 
 40 
 
 42 
 
 68 
 
 71 
 
 83 
 
 87 
 
 4 
 
 1834 . 
 
 5 
 
 5 
 
 4 
 
 4 
 
 9 
 
 9 
 
 31 
 
 31 
 
 45 
 
 46 
 
 76 
 
 77 
 
 85 
 
 86 
 
 3 
 
 1835 . 
 
 4 
 
 4 
 
 4 
 
 4 
 
 8 
 
 8 
 
 29 
 
 28 
 
 40 
 
 39 
 
 69 
 
 67 
 
 77 
 
 75 
 
 4 
 
 1836 . 
 
 3 
 
 3 
 
 10 
 
 9 
 
 13 
 
 12 
 
 25 
 
 24 
 
 47 
 
 44 
 
 72 
 
 68 
 
 85 
 
 80 
 
 4 
 
 1837 . 
 
 11 
 
 10 
 
 5 
 
 5 
 
 16 
 
 15 
 
 39 
 
 36 
 
 41 
 
 37 
 
 80 
 
 73 
 
 96 
 
 88 
 
 4 
 
 1838 . 
 
 5 
 
 4 
 
 6 
 
 5 
 
 11 
 
 10 
 
 23 
 
 20 
 
 51 
 
 45 
 
 74 
 
 65 
 
 85 
 
 75 
 
 3 
 
 1839 . 
 
 2 
 
 2 
 
 3 
 
 3 
 
 5 
 
 4 
 
 35 
 
 30 
 
 38 
 
 32 
 
 73 
 
 62 
 
 78 
 
 67 
 
 3 
 
 1840 . 
 
 4 
 
 3 
 
 7 
 
 6 
 
 11 
 
 9 
 
 22 
 
 18 
 
 38 
 
 31 
 
 60 
 
 50 
 
 71 
 
 59 
 
 3 
 
 1841 . 
 
 5 
 
 4 
 
 3 
 
 2 
 
 8 
 
 6 
 
 64 
 
 51 
 
 38 
 
 30 
 
 102 
 
 82 
 
 110 
 
 88 
 
 5 
 
 1842 . 
 
 3 
 
 2 
 
 5 
 
 4 
 
 8 
 
 6 
 
 47 
 
 36 
 
 62 
 
 48 
 
 109 
 
 85 
 
 117 
 
 91 
 
 5 
 
 1843 . 
 
 7 
 
 5 
 
 1 
 
 1 
 
 8 
 
 6 
 
 24 
 
 18 
 
 35 
 
 26 
 
 59 
 
 44 
 
 67 
 
 50 
 
 3 
 
 1844 . 
 
 11 
 
 8 
 
 5 
 
 4 
 
 16 
 
 12 
 
 27 
 
 20 
 
 37 
 
 27 
 
 64 
 
 47 
 
 80 
 
 58 
 
 3 
 
 1845 . 
 
 6 
 
 4 
 
 6 
 
 4 
 
 12 
 
 8 
 
 34 
 
 24 
 
 53 
 
 37 
 
 87 
 
 61 
 
 99 
 
 70 
 
 3 
 
 1846 . 
 
 13 
 
 9 
 
 4 
 
 3 
 
 17 
 
 12 
 
 40 
 
 27 
 
 50 
 
 34 
 
 90 
 
 62 
 
 107 
 
 73 
 
 4 
 
 1847 . 
 
 8 
 
 5 
 
 3 
 
 2 
 
 11 
 
 7 
 
 34 
 
 23 
 
 48 
 
 32 
 
 82 
 
 55 
 
 93 
 
 62 
 
 3 
 
 1848 . 
 
 6 
 
 4 
 
 5 
 
 3 
 
 11 
 
 7 
 
 31 
 
 20 
 
 57 
 
 37 
 
 88 
 
 57 
 
 99 
 
 64 
 
 3 
 
 1849 . 
 
 5 
 
 3 
 
 4 
 
 3 
 
 9 
 
 6 
 
 25 
 
 16 
 
 52 
 
 33 
 
 77 
 
 48 
 
 86 
 
 54 
 
 2 
 
 1850 . 
 
 8 
 
 5 
 
 5 
 
 3 
 
 13 
 
 8 
 
 29 
 
 18 
 
 50 
 
 31 
 
 79 
 
 48 
 
 92 
 
 56 
 
 2 
 
 1851 . 
 
 7 
 
 4 
 
 6 
 
 4 
 
 13 
 
 8 
 
 46 
 
 27 
 
 64 
 
 38 
 
 110 
 
 65 
 
 123 
 
 73 
 
 3 
 
 1852 . 
 
 16 
 
 9 
 
 11 
 
 6 
 
 27 
 
 16 
 
 42 
 
 24 
 
 75 
 
 43 
 
 117 
 
 67 
 
 144 
 
 83 
 
 3 
 
 1853 . 
 
 4 
 
 2 
 
 1 
 
 1 
 
 5 
 
 3 
 
 52 
 
 29 
 
 110 
 
 62 
 
 162 
 
 91 
 
 167 
 
 94 
 
 3 
 
 1854 . 
 
 12 
 
 7 
 
 10 
 
 5 
 
 22 
 
 12 
 
 47 
 
 26 
 
 133 
 
 73 
 
 180 
 
 98 
 
 202 
 
 110 
 
 4 
 
 1855 . 
 
 14 
 
 7 
 
 13 
 
 7 
 
 27 
 
 14 
 
 50 
 
 27 
 
 90 
 
 48 
 
 140 
 
 74 
 
 167 
 
 89 
 
 3 
 
 1856 . 
 
 51 
 
 26 
 
 8 
 
 4 
 
 59 
 
 31 
 
 43 
 
 22 
 
 98 
 
 51 
 
 141 
 
 73 
 
 200 
 
 103 
 
 4 
 
 1857 . 
 
 33 
 
 17 
 
 4 
 
 2 
 
 37 
 
 19 
 
 40 
 
 20 
 
 92 
 
 46 
 
 132 
 
 66 
 
 169 
 
 85 
 
 3 
 
 1858 . 
 
 24 
 
 12 
 
 3 
 
 1 
 
 27 
 
 13 
 
 42 
 
 21 
 
 63 
 
 31 
 
 105 
 
 52 
 
 132 
 
 65 
 
 2 
 
 1859 . 
 
 18 
 
 9 
 
 9 
 
 4 
 
 27 
 
 13 
 
 35 
 
 17 
 
 76 
 
 36 
 
 111 
 
 53 
 
 138 
 
 66 
 
 3 
 
 1860 . 
 
 9 
 
 4 
 
 12 
 
 6 
 
 21 
 
 10 
 
 41 
 
 19 
 
 91 
 
 42 
 
 132 
 
 62 
 
 153 
 
 71 
 
 3 
 
 1861 . 
 
 15 
 
 7 
 
 10 
 
 5 
 
 25 
 
 11 
 
 33 
 
 15 
 
 96 
 
 44 
 
 129 
 
 59 
 
 154 
 
 70 
 
 3 
 
 1862 . 
 
 28 
 
 12 
 
 1 
 
 « • « 
 
 29 
 
 13 
 
 50 
 
 22 
 
 91 
 
 40 
 
 141 
 
 63 
 
 170 
 
 75 
 
 3 
 
 1863 . 
 
 19 
 
 8 
 
 6 
 
 3 
 
 25 
 
 11 
 
 55 
 
 24 
 
 99 
 
 43 
 
 154 
 
 67 
 
 179 
 
 77 
 
 3 
 
 1864 . 
 
 21 
 
 9 
 
 2 
 
 1 
 
 23 
 
 10 
 
 47 
 
 20 
 
 100 
 
 42 
 
 147 
 
 62 
 
 170 
 
 72 
 
 3 
 
 1865 . 
 
 9 
 
 4 
 
 5 
 
 2 
 
 14 
 
 6 
 
 52 
 
 21 
 
 83 
 
 34 
 
 135 
 
 56 
 
 149 
 
 61 
 
 3 
 
 1866 . 
 
 19 
 
 8 
 
 7 
 
 3 
 
 26 
 
 10 
 
 49 
 
 20 
 
 82 
 
 33 
 
 131 
 
 53 
 
 157 
 
 63 
 
 3 
 
MISCELLANEOUS CAUSES OF DEATH 
 
 481 
 
 Table 120. —Number of deaths and rate of death, per 100,000 living inhabitants, by 
 
 violence, etc. —Continued. 
 
 Year. 
 
 1867 . 
 
 1868 . 
 
 1869 . 
 
 1870 . 
 
 1871 . 
 
 1872 . 
 
 1873 . 
 
 1874 . 
 
 1875 . 
 
 1876 . 
 
 1877 . 
 
 1878 . 
 
 1879 . 
 
 1880 . 
 
 1881 . 
 
 1882 . 
 
 1883 . 
 
 1884 . 
 
 1885 . 
 
 1886 . 
 
 1887 . 
 
 1888 . 
 
 1889 . 
 
 1890 . 
 
 1891 . 
 
 1892 . 
 
 1893 . 
 
 1894 . 
 
 1895 . 
 
 1896 . 
 
 1897 . 
 
 1898 . 
 
 1899 . 
 
 1900 . 
 
 1901 . 
 
 1902 . 
 
 1903 . 
 
 1904 . 
 
 1905 . 
 
 1906 . 
 
 1907 . 
 
 1908 . 
 
 1909 . 
 
 1910 . 
 
 1911 . 
 
 1912 . 
 
 1913 . 
 
 1914 . 
 
 1915 . 
 
 1916 . 
 
 1917 . 
 
 1918 . 
 
 1919 . 
 
 1920 . 
 
 D = death. R = rate. 
 
 Homicides and suicides. 
 
 Accidents. 
 
 Total. 
 
 Percentage 
 to total 
 deaths. 
 
 Homi¬ 
 
 cides. 
 
 Suicides. 
 
 Total. 
 
 Drown- 
 
 ings. 
 
 Other ac¬ 
 cidents- 
 
 Total. 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 7 
 
 3 
 
 9 
 
 4 
 
 16 
 
 6 
 
 43 
 
 17 
 
 69 
 
 27 
 
 112 
 
 44 
 
 128 
 
 50 
 
 2 
 
 9 
 
 3 
 
 9 
 
 3 
 
 18 
 
 7 
 
 52 
 
 20 
 
 106 
 
 41 
 
 158 
 
 61 
 
 176 
 
 68 
 
 3 
 
 4 
 
 2 
 
 9 
 
 3 
 
 13 
 
 5 
 
 42 
 
 16 
 
 81 
 
 30 
 
 123 
 
 46 
 
 136 
 
 51 
 
 2 
 
 18 
 
 7 
 
 16 
 
 6 
 
 34 
 
 12 
 
 58 
 
 21 
 
 97 
 
 36 
 
 155 
 
 57 
 
 189 
 
 69 
 
 3 
 
 13 
 
 5 
 
 6 
 
 2 
 
 19 
 
 7 
 
 40 
 
 14 
 
 97 
 
 35 
 
 137 
 
 49 
 
 156 
 
 56 
 
 2 
 
 8 
 
 3 
 
 15 
 
 5 
 
 23 
 
 8 
 
 52 
 
 18 
 
 120 
 
 42 
 
 172 
 
 60 
 
 195 
 
 68 
 
 2 
 
 9 
 
 3 
 
 22 
 
 8 
 
 31 
 
 11 
 
 59 
 
 20 
 
 131 
 
 45 
 
 190 
 
 65 
 
 221 
 
 76 
 
 3 
 
 6 
 
 2 
 
 20 
 
 7 
 
 26 
 
 9 
 
 50 
 
 17 
 
 124 
 
 42 
 
 174 
 
 58 
 
 200 
 
 67 
 
 3 
 
 8 
 
 3 
 
 20 
 
 7 
 
 28 
 
 9 
 
 42 
 
 14 
 
 115 
 
 38 
 
 157 
 
 51 
 
 185 
 
 61 
 
 3 
 
 8 
 
 3 
 
 13 
 
 4 
 
 21 
 
 7 
 
 59 
 
 19 
 
 121 
 
 39 
 
 180 
 
 58 
 
 201 
 
 65 
 
 3 
 
 27 
 
 8 
 
 18 
 
 6 
 
 45 
 
 14 
 
 44 
 
 14 
 
 90 
 
 28 
 
 134 
 
 42 
 
 179 
 
 56 
 
 2 
 
 17 
 
 5 
 
 21 
 
 6 
 
 38 
 
 12 
 
 52 
 
 16 
 
 78 
 
 24 
 
 130 
 
 40 
 
 168 
 
 52 
 
 3 
 
 35 
 
 11 
 
 15 
 
 5 
 
 50 
 
 15 
 
 51 
 
 15 
 
 78 
 
 24 
 
 129 
 
 39 
 
 179 
 
 54 
 
 2 
 
 47 
 
 14 
 
 18 
 
 5 
 
 65 
 
 19 
 
 54 
 
 16 
 
 120 
 
 35 
 
 174 
 
 51 
 
 239 
 
 71 
 
 3 
 
 65 
 
 19 
 
 23 
 
 7 
 
 88 
 
 25 
 
 39 
 
 11 
 
 84 
 
 24 
 
 123 
 
 36 
 
 211 
 
 61 
 
 2 
 
 79 
 
 22 
 
 30 
 
 9 
 
 109 
 
 31 
 
 42 
 
 12 
 
 114 
 
 32 
 
 156 
 
 44 
 
 265 
 
 75 
 
 3 
 
 20 
 
 6 
 
 26 
 
 7 
 
 46 
 
 13 
 
 55 
 
 15 
 
 135 
 
 38 
 
 190 
 
 53 
 
 236 
 
 66 
 
 3 
 
 25 
 
 7 
 
 20 
 
 5 
 
 45 
 
 12 
 
 58 
 
 16 
 
 156 
 
 43 
 
 214 
 
 58 
 
 259 
 
 71 
 
 3 
 
 15 
 
 4 
 
 28 
 
 7 
 
 43 
 
 11 
 
 42 
 
 11 
 
 169 
 
 45 
 
 211 
 
 56 
 
 254 
 
 68 
 
 3 
 
 19 
 
 5 
 
 31 
 
 8 
 
 50 
 
 13 
 
 36 
 
 9 
 
 129 
 
 34 
 
 165 
 
 43 
 
 215 
 
 56 
 
 3 
 
 15 
 
 4 
 
 43 
 
 11 
 
 58 
 
 15 
 
 50 
 
 13 
 
 152 
 
 39 
 
 202 
 
 52 
 
 260 
 
 67 
 
 3 
 
 15 
 
 4 
 
 35 
 
 8 
 
 50 
 
 12 
 
 45 
 
 11 
 
 172 
 
 41 
 
 217 
 
 52 
 
 267 
 
 64 
 
 3 
 
 30 
 
 7 
 
 32 
 
 7 
 
 62 
 
 15 
 
 62 
 
 15 
 
 160 
 
 37 
 
 222 
 
 52 
 
 284 
 
 67 
 
 3 
 
 27 
 
 6 
 
 25 
 
 6 
 
 52 
 
 12 
 
 73 
 
 17 
 
 166 
 
 38 
 
 239 
 
 55 
 
 291 
 
 67 
 
 3 
 
 10 
 
 2 
 
 39 
 
 9 
 
 49 
 
 11 
 
 51 
 
 12 
 
 222 
 
 50 
 
 273 
 
 62 
 
 322 
 
 73 
 
 3 
 
 21 
 
 5 
 
 48 
 
 11 
 
 69 
 
 15 
 
 61 
 
 14 
 
 239 
 
 53 
 
 300 
 
 67 
 
 369 
 
 82 
 
 3 
 
 22 
 
 5 
 
 50 
 
 11 
 
 72 
 
 16 
 
 57 
 
 12 
 
 262 
 
 57 
 
 319 
 
 79 
 
 391 
 
 86 
 
 4 
 
 18 
 
 4 
 
 48 
 
 10 
 
 66 
 
 14 
 
 66 
 
 14 
 
 207 
 
 45 
 
 273 
 
 59 
 
 339 
 
 73 
 
 4 
 
 26 
 
 6 
 
 43 
 
 9 
 
 69 
 
 15 
 
 44 
 
 9 
 
 324 
 
 69 
 
 368 
 
 78 
 
 437 
 
 93 
 
 4 
 
 20 
 
 4 
 
 48 
 
 10 
 
 68 
 
 14 
 
 60 
 
 13 
 
 261 
 
 55 
 
 321 
 
 67 
 
 389 
 
 81 
 
 4 
 
 21 
 
 4 
 
 60 
 
 12 
 
 81 
 
 17 
 
 56 
 
 12 
 
 231 
 
 48 
 
 287 
 
 59 
 
 368 
 
 76 
 
 4 
 
 32 
 
 6 
 
 56 
 
 11 
 
 88 
 
 18 
 
 31 
 
 6 
 
 226 
 
 46 
 
 257 
 
 52 
 
 345 
 
 70 
 
 3 
 
 13 
 
 3 
 
 54 
 
 11 
 
 67 
 
 13 
 
 63 
 
 13 
 
 265 
 
 53 
 
 328 
 
 66 
 
 395 
 
 79 
 
 4 
 
 27 
 
 5 
 
 72 
 
 14 
 
 99 
 
 20 
 
 57 
 
 11 
 
 311 
 
 61 
 
 368 
 
 73 
 
 467 
 
 92 
 
 4 
 
 22 
 
 4 
 
 61 
 
 12 
 
 83 
 
 16 
 
 56 
 
 11 
 
 275 
 
 54 
 
 331 
 
 64 
 
 414 
 
 81 
 
 4 
 
 16 
 
 3 
 
 60 
 
 12 
 
 76 
 
 15 
 
 56 
 
 11 
 
 326 
 
 63 
 
 382 
 
 73 
 
 458 
 
 88 
 
 4 
 
 14 
 
 3 
 
 58 
 
 11 
 
 72 
 
 14 
 
 44 
 
 8 
 
 324 
 
 61 
 
 368 
 
 70 
 
 440 
 
 83 
 
 4 
 
 24 
 
 4 
 
 81 
 
 15 
 
 105 
 
 20 
 
 47 
 
 9 
 
 313 
 
 59 
 
 362 
 
 68 
 
 467 
 
 87 
 
 4 
 
 19 
 
 4 
 
 88 
 
 16 
 
 107 
 
 20 
 
 47 
 
 9 
 
 371 
 
 69 
 
 418 
 
 77 
 
 525 
 
 97 
 
 5 
 
 26 
 
 5 
 
 70 
 
 13 
 
 96 
 
 18 
 
 61 
 
 11 
 
 372 
 
 68 
 
 433 
 
 79 
 
 529 
 
 97 
 
 5 
 
 41 
 
 7 
 
 83 
 
 15 
 
 124 
 
 22 
 
 54 
 
 10 
 
 396 
 
 72 
 
 450 
 
 81 
 
 574 
 
 104 
 
 5 
 
 19 
 
 3 
 
 98 
 
 18 
 
 117 
 
 21 
 
 55 
 
 10 
 
 319 
 
 57 
 
 374 
 
 67 
 
 491 
 
 88 
 
 5 
 
 18 
 
 3 
 
 101 
 
 18 
 
 119 
 
 21 
 
 47 
 
 8 
 
 335 
 
 59 
 
 382 
 
 67 
 
 501 
 
 88 
 
 5 
 
 14 
 
 2 
 
 77 
 
 13 
 
 91 
 
 16 
 
 49 
 
 9 
 
 358 
 
 63 
 
 407 
 
 71 
 
 498 
 
 87 
 
 5 
 
 27 
 
 5 
 
 100 
 
 17 
 
 127 
 
 22 
 
 45 
 
 8 
 
 302 
 
 52 
 
 347 
 
 60 
 
 474 
 
 82 
 
 5 
 
 22 
 
 4 
 
 88 
 
 15 
 
 110 
 
 19 
 
 52 
 
 9 
 
 313 
 
 54 
 
 365 
 
 62 
 
 475 
 
 81 
 
 5 
 
 41 
 
 7 
 
 118 
 
 20 
 
 159 
 
 27 
 
 58 
 
 10 
 
 349 
 
 59 
 
 407 
 
 69 
 
 566 
 
 96 
 
 6 
 
 44 
 
 7 
 
 138 
 
 23 
 
 182 
 
 31 
 
 46 
 
 8 
 
 373 
 
 63 
 
 419 
 
 70 
 
 601 
 
 101 
 
 6 
 
 48 
 
 8 
 
 101 
 
 17 
 
 149 
 
 25 
 
 58 
 
 10 
 
 360 
 
 60 
 
 418 
 
 70 
 
 567 
 
 94 
 
 6 
 
 53 
 
 9 
 
 94 
 
 15 
 
 147 
 
 24 
 
 59 
 
 10 
 
 352 
 
 58 
 
 411 
 
 68 
 
 558 
 
 92 
 
 5 
 
 52 
 
 8 
 
 100 
 
 16 
 
 152 
 
 25 
 
 64 
 
 10 
 
 560 
 
 91 
 
 624 
 
 102 
 
 776 
 
 127 
 
 7 
 
 65 
 
 11 
 
 101 
 
 16 
 
 166 
 
 27 
 
 60 
 
 10 
 
 575 
 
 93 
 
 635 
 
 103 
 
 801 
 
 130 
 
 5 
 
 57 
 
 8 
 
 98 
 
 14 
 
 155 
 
 21 
 
 64 
 
 9 
 
 544 
 
 75 
 
 608 
 
 84 
 
 763 
 
 106 
 
 7 
 
 52 
 
 7 
 
 88 
 
 12 
 
 140 
 
 19 
 
 37 
 
 5 
 
 465 
 
 63 
 
 502 
 
 68 
 
 642 
 
 87 
 
 6 
 
482 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 The total rate declined from 139 in 1812 to 50 in 1843. Gradually rising 
 again to 110 by 1854, it slowly receded to 50 in 1867. From this date, though 
 with wavering steps, the rate gradually rose to 130 in 1918. By 1920 it had 
 fallen to 87. 
 
 For homicide, the annual rates have varied within wide limits, the extremes 
 being zero in 1831 and 26 in 1856. While relatively high and low annual rates 
 often alternated, a decided tendency to epidemic waves covering periods of 
 years is evident. Conspicuous in this regard are the periods 1818-1821, 1854- 
 1859, 1879-1882, 1913-1920. The high rates (20) attained in 1812 and in 
 certain years of the fifth, sixth, and ninth decades of the nineteenth century 
 occurred in times of intense political rivalry, which were often characterized 
 by feuds and riots. 
 
 Graph 30 (from table 120). Annual crude mortality-rates from different 
 types of violence, from 1812 to 1920, inclusive- 
 
 For suicides, the fluctuation in the rates from year to year, especially in 
 the period prior to 1880, was even more marked than for homicide. The 
 extremes were rates of 1 in 1843, 1853, 1858, and 1864, and of 17 in 1818 for 
 the early years, and of 23 in 1914 for the later years. It will be noted that 
 the rates, which were low in 1812 to 1814, rose after the close of the war in 
 1815 and maintained a comparatively high level for over 15 years. After 
 this period the course of the rates was very irregular, but, on the whole, rela¬ 
 tively low until after 1870. During the Civil War the rates were conspicuously 
 low. After 1880 the rates gradually rose and the annual fluctuations became 
 much less marked. From the peak-rate of 23 attained in 1914, the rate receded 
 during the period of the World War and by 1920 had fallen 50 per cent to 12, 
 the lowest rate since 1903. From a special table in the annual report for 1892, 
 
MISCELLANEOUS CAUSES OF DEATH 
 
 483 
 
 giving the annual number of deaths from suicide from 1875 to 1892, inclusive, 
 it appears that the total of 489 suicides were distributed by sex and color as 
 follows: White males, 394; white females, 87; colored males, 5; and colored 
 females, 3. Accidental drowning, until 1830 a serious rival of all other acci¬ 
 dents as a cause of death, gradually declined from peak-rate of 75 in 1817 to 
 the relatively inconsiderable rate of 5 in 1920. While the course of the rates 
 was subject to fluctuations from year to year and over longer periods, it is, on 
 the whole, comparatively regular. 
 
 The rates for deaths from all other accidents have varied within wide limits, 
 from 20 in 1825 to 93 in 1918. Though subject to marked variations in level, 
 in general the course of the rates between 1812 and 1843 was downward. A 
 succession of three rather smoothly outlined waves occurred between 1844 and 
 1878. The course of the rates since 1881 is marked by a long upward sweep, 
 broken here and there by crests and depressions, to 93 in 1918, and with a 
 
 Table 121.— Absolute figures of deaths by accident, except drowning, for the years 1900, 
 
 1905, 1910, 1915, and 1920. 
 
 Causes of death. 
 
 1900 
 
 1905 
 
 1910 
 
 1915 
 
 1920 
 
 Poisoning by food. (164). 
 
 
 
 1 
 
 4 
 
 8 
 
 Other acute poisonings. (165). 
 
 9 
 
 20 
 
 8 
 
 6 
 
 9 
 
 Conflagration. (166) . 
 
 13 
 
 77 
 
 6 
 
 5 
 
 9 
 
 Burns. (167) . 
 
 
 
 80 
 
 70 
 
 81 
 
 Deleterious gases. (168). 
 
 16 
 
 14 
 
 16 
 
 10 
 
 28 
 
 Traumatism by firearms. (170). 
 
 9 
 
 9 
 
 7 
 
 2 
 
 6 
 
 Traumatism by cutting and piercing instruments. (171) .... 
 
 • • • • 
 
 • • • • 
 
 1 
 
 1 
 
 1 
 
 Traumatism by fall. (172). 
 
 7 
 
 37 
 
 80 
 
 81 
 
 109 
 
 Traumatism in mines and quarries. (173). 
 
 
 
 1 
 
 
 1 
 
 Traumatism by machines. (174). 
 
 
 
 15 
 
 5 
 
 22 
 
 Traumatism by crushing. (Vehicles, etc.) (175). 
 
 72 
 
 88 
 
 93 
 
 76 
 
 161 
 
 Traumatism by animals. (176). 
 
 
 
 2 
 
 2 
 
 2 
 
 Traumatism by electricity. (Lightning excepted.). 
 
 3 
 
 6 
 
 9 
 
 • • • • 
 
 8 
 
 Fractures. (Cause not specified.) (185). 
 
 73 
 
 63 
 
 7 
 
 2 
 
 • • • • 
 
 Other external violence. (186). 
 
 59 
 
 57 
 
 30 
 
 12 
 
 20 
 
 Total . 
 
 254 
 
 314 
 
 366 
 
 276 
 
 465 
 
 recession to 63 in 1920. The unusually high rates for 1917 and 1918 were 
 associated with a considerable increase of accidents in connection with the 
 feverish war activities. For example, in 1918, the number of deaths from 
 machinery, falls, vehicles, and “ other external violence ” exceeded that for 
 1920 by 110, or 24 per cent. 
 
 From table 121, in which are given the absolute figures for the main cate¬ 
 gories of accidents except drowning for the years 1900, 1905, 1910, 1915, and 
 1920, a very good idea is gained of the relative lethal importance of the 
 various types of accidents. Owing to modifications in the official classification, 
 the rubrics poisoning, burns, falls, and other external violence in 1900 and 
 1905 are not strictly comparable with those in the later years. The predomi¬ 
 nant importance of deaths due to burns, falls (with fractures due to falls), 
 and vehicles is clear. The increase in the number of deaths under the latter 
 rubric was due to automobiles. The small part played by machinery indicates 
 that the death-toll paid directly to manufacturing is relatively light. 
 
484 PUBLIC HEALTH ADMINISTKATION, ETC., IN' BALTIMOBE 
 
 The influence of age and color upon accidental death in an average year is 
 illustrated in table 122. The high proportion of negroes and of non-residents 
 is striking. The large proportion of the deaths attributed to falls in individ¬ 
 uals over the sixty-fifth year indicates the conspicuous part played by falls 
 resulting in fractures followed by death in the aged. Nearly half the vehicular 
 deaths were caused by injuries from automobiles and a strikingly large share of 
 all deaths from vehicular accidents occurred in non-residents, most of whom 
 were brought to the city for surgical care after injury. 
 
 From the rates averaged for 5-year periods (table 123, graph 31), it is evi¬ 
 dent that the chance of a violent end of life in 1915-1920 was nearly as good 
 as it was in 1812-1815. Drowning is the only one of this group of causes of 
 death that has shown any decrease in rate. Homicide holds its own, and 
 
 Table 122.— Influence oj age and color upon the absolute number of deaths by accident 
 
 for 1917. 
 
 
 Poisoning. 
 
 Burns, conflagrat ions. 
 
 Burns and scalds- 
 
 Asphyxia, acid. 
 
 Gas from oil stove. 
 
 Illuminating gas. 
 
 Suffocation in bed. 
 
 Drowning. 
 
 Firearms. 
 
 Cutting instruments. 
 
 Falls. 
 
 Machinery. 
 
 Elevators. 
 
 Automobiles- 
 
 Street cars. 
 
 Steam railroads. 
 
 Other vehicles. 
 
 Landslides. 
 
 Total . 
 
 16 
 
 13 
 
 78 
 
 1 
 
 4 
 
 18 
 
 5 
 
 64 
 
 9 
 
 1 
 
 115 
 
 13 
 
 7 
 
 76 
 
 47 
 
 27 
 
 15 
 
 2 
 
 White . 
 
 11 
 
 11 
 
 50 
 
 • • 
 
 4 
 
 18 
 
 3 
 
 42 
 
 8 
 
 1 
 
 102 
 
 8 
 
 2 
 
 68 
 
 34 
 
 20 
 
 13 
 
 1 
 
 Colored . 
 
 5 
 
 2 
 
 28 
 
 1 
 
 # # 
 
 
 2 
 
 22 
 
 1 
 
 
 13 
 
 5 
 
 5 
 
 8 
 
 13 
 
 7 
 
 2 
 
 1 
 
 Non-residents . 
 
 • • 
 
 4 
 
 11 
 
 
 
 
 
 8 
 
 6 
 
 
 17 
 
 3 
 
 7 
 
 21 
 
 10 
 
 9 
 
 4 
 
 
 Under 1 year. 
 
 • • 
 
 2 
 
 3 
 
 
 
 
 5 
 
 
 
 
 
 
 
 
 
 
 
 
 Between 1 and 2 yrs. 
 
 1 
 
 1 
 
 6 
 
 • • 
 
 1 
 
 
 
 
 
 
 2 
 
 • • 
 
 • • 
 
 1 
 
 
 
 
 
 2 to 4 years. 
 
 3 
 
 • • 
 
 23 
 
 • • 
 
 2 
 
 
 
 
 
 
 6 
 
 • • 
 
 • • 
 
 8 
 
 3 
 
 
 
 
 5 to 14 years. 
 
 1 
 
 • • 
 
 16 
 
 
 
 
 
 12 
 
 1 
 
 
 5 
 
 • • 
 
 1 
 
 26 
 
 7 
 
 1 
 
 3 
 
 
 15 to 24 years. 
 
 1 
 
 1 
 
 5 
 
 
 
 
 
 8 
 
 4 
 
 
 6 
 
 4 
 
 2 
 
 9 
 
 7 
 
 3 
 
 • • 
 
 
 25 to 44 years. 
 
 5 
 
 5 
 
 8 
 
 # , 
 
 1 
 
 4 
 
 
 28 
 
 4 
 
 
 18 
 
 2 
 
 3 
 
 14 
 
 13 
 
 13 
 
 8 
 
 1 
 
 45 to 65 years. 
 
 5 
 
 1 
 
 12 
 
 1 
 
 • • 
 
 10 
 
 
 14 
 
 • • 
 
 
 31 
 
 7 
 
 1 
 
 13 
 
 14 
 
 10 
 
 3 
 
 1 
 
 66 years and over... 
 
 • • 
 
 3 
 
 5 
 
 • • 
 
 • • 
 
 4 
 
 
 2 
 
 • • 
 
 1 
 
 47 
 
 • • 
 
 • • 
 
 5 
 
 3 
 
 • • 
 
 1 
 
 • • 
 
 suicides and accidents other than drowning have actually increased. The rate 
 for suicide has indeed multiplied three times. The course of the curves for 
 homicide and suicide suggests the possibility that to some degree the ultimate 
 motives underlying these acts are interrelated. It will be noted that when the 
 rates for one are high, those for the other are commonly low. The curve of 
 the rates for deaths from intentional violence—homicides and suicides taken 
 together—shows a very distinct rise over the 109 years under review, and is 
 marked by four definite peaks, of which each of the last three is higher than 
 its predecessor. These peaks fall in the 5-year periods 1815-1820, 1856-1860, 
 1881-1885, and 1911-1915, and are therefore separated by periods of about 
 30 years. The curve for the rates for unintentional violence—all accidental 
 deaths—falls rather regularly on the whole between 1812-1815 and 1876- 
 1880, and then ascending steadily throughout the rest of its course, and in 
 spite of the constantly decreasing importance of drowning, ends at a level of 
 only 20 per cent less than at the beginning. As judged by rates averaged 
 
MISCELLANEOUS CAUSES OF DEATH 
 
 485 
 
 Table 123 .—Average rate oj death, per 100,000 living inhabitants, by 5- and 10-year 
 
 periods from violence, from 1812 to 1920, inclusive. 
 
 Periods. 
 
 Homicides and suicides. 
 
 Accidents- 
 
 Total. 
 
 Homi¬ 
 
 cides- 
 
 Suicides- 
 
 Total. 
 
 Drown- 
 
 ings. 
 
 Other ac¬ 
 cidents. 
 
 Total. 
 
 By 5-year 
 periods- 
 
 BylO-year 
 
 periods. 
 
 By 5-year 
 
 periods- 
 
 BylO-year 
 
 periods- 
 
 By 5-year 
 
 periods. 
 
 BylO-year 
 
 periods- 
 
 By 5-year 
 
 periods. 
 
 BylO-year 
 
 periods. 
 
 By 5-year 
 
 periods. 
 
 BylO-year 
 
 periods. 
 
 By 5-year 
 
 periods. 
 
 BylO-year 
 
 periods. 
 
 By 5-year 
 
 periods. 
 
 BylO-year 
 
 periods. 
 
 1812-15 . 
 
 8 
 
 • • • 
 
 5 
 
 
 12 
 
 • • • 
 
 52 
 
 • • • 
 
 50 
 
 • • • 
 
 102 
 
 • • • 
 
 114 
 
 • • • 
 
 1816-20 . 
 
 7 
 
 7 
 
 8 
 
 7 
 
 15 
 
 14 
 
 51 
 
 50 
 
 48 
 
 49 
 
 99 
 
 100 
 
 114 
 
 114 
 
 1821-25 . 
 
 7 
 
 • • • 
 
 7 
 
 • • • 
 
 14 
 
 • • • 
 
 43 
 
 ... 
 
 47 
 
 • • • 
 
 90 
 
 ... 
 
 104 
 
 ... 
 
 1826-30 . 
 
 5 
 
 6 
 
 7 
 
 7 
 
 12 
 
 13 
 
 41 
 
 42 
 
 46 
 
 47 
 
 87 
 
 89 
 
 99 
 
 101 
 
 1831-35 . 
 
 5 
 
 • • • 
 
 5 
 
 • • • 
 
 10 
 
 • • • 
 
 29 
 
 • • • 
 
 43 
 
 • • • 
 
 72 
 
 • • • 
 
 82 
 
 • • • 
 
 1836-40 . 
 
 4 
 
 5 
 
 6 
 
 6 
 
 10 
 
 10 
 
 26 
 
 27 
 
 38 
 
 41 
 
 64 
 
 68 
 
 74 
 
 78 
 
 1841-45 . 
 
 5 
 
 • • • 
 
 3 
 
 • • • 
 
 8 
 
 • • • 
 
 30 
 
 • • • 
 
 34 
 
 • • • 
 
 64 
 
 • • • 
 
 71 
 
 • • • 
 
 1846-50 . 
 
 5 
 
 5 
 
 3 
 
 3 
 
 8 
 
 8 
 
 21 
 
 25 
 
 33 
 
 34 
 
 54 
 
 59 
 
 62 
 
 67 
 
 1851-55 . 
 
 6 
 
 • • • 
 
 5 
 
 • • • 
 
 10 
 
 • • • 
 
 27 
 
 • • • 
 
 53 
 
 • • • 
 
 79 
 
 • • • 
 
 90 
 
 ... 
 
 1856-60 . 
 
 14 
 
 10 
 
 4 
 
 4 
 
 17 
 
 14 
 
 20 
 
 23 
 
 41 
 
 47 
 
 61 
 
 70 
 
 78 
 
 84 
 
 1861-65 . 
 
 8 
 
 • • • 
 
 2 
 
 • • • 
 
 10 
 
 • • • 
 
 20 
 
 ... 
 
 41 
 
 • • • 
 
 61 
 
 • • • 
 
 71 
 
 • • • 
 
 1866-70 . 
 
 4 
 
 6 
 
 4 
 
 3 
 
 8 
 
 9 
 
 19 
 
 20 
 
 33 
 
 37 
 
 52 
 
 57 
 
 60 
 
 66 
 
 1871-75 . 
 
 3 
 
 • • • 
 
 6 
 
 • • • 
 
 9 
 
 • • • 
 
 17 
 
 • • • 
 
 40 
 
 • • • 
 
 57 
 
 • • • 
 
 66 
 
 • • • 
 
 1876-80 . 
 
 8 
 
 6 
 
 5 
 
 5 
 
 13 
 
 11 
 
 16 
 
 16 
 
 30 
 
 35 
 
 46 
 
 51 
 
 59 
 
 63 
 
 1881-85 . 
 
 12 
 
 • • • 
 
 7 
 
 • • • 
 
 19 
 
 • • • 
 
 13 
 
 • • • 
 
 36 
 
 • • • 
 
 49 
 
 • • • 
 
 68 
 
 
 1886-90 . 
 
 5 
 
 8 
 
 8 
 
 8 
 
 13 
 
 16 
 
 13 
 
 13 
 
 38 
 
 37 
 
 51 
 
 50 
 
 64 
 
 66 
 
 1891-95 . 
 
 4 
 
 • • • 
 
 10 
 
 • • • 
 
 14 
 
 ... 
 
 12 
 
 • • • 
 
 55 
 
 ... 
 
 67 
 
 • • • 
 
 81 
 
 • • • 
 
 1896-1900 . 
 
 5 
 
 4 
 
 12 
 
 11 
 
 16 
 
 15 
 
 11 
 
 12 
 
 52 
 
 54 
 
 63 
 
 65 
 
 80 
 
 80 
 
 1901-05 . 
 
 4 
 
 • • • 
 
 13 
 
 • • • 
 
 17 
 
 ... 
 
 10 
 
 • • • 
 
 61 
 
 • • • 
 
 71 
 
 • • • 
 
 87 
 
 • • • 
 
 1906-10 . 
 
 4 
 
 4 
 
 15 
 
 14 
 
 20 
 
 18 
 
 10 
 
 10 
 
 64 
 
 62 
 
 73 
 
 72 
 
 93 
 
 90 
 
 1911-15 . 
 
 6 
 
 • • • 
 
 18 
 
 • • • 
 
 25 
 
 • • • 
 
 9 
 
 • • • 
 
 57 
 
 • • • 
 
 66 
 
 
 91 
 
 • • • 
 
 1916-20 . 
 
 8 
 
 7 
 
 15 
 
 17 
 
 23 
 
 24 
 
 9 
 
 9 
 
 76 
 
 67 
 
 85 
 
 76 
 
 108 
 
 100 
 
 Graph 31 (from table 123). Crude mortality-rates from different types of 
 violence, averaged by 5-year periods, from 1812 to 1920, inclusive. 
 
486 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 for 5-year periods, between 1812 and 1920, the mortality for intentional 
 violence increased by 100 per cent, the mortality for unintentional violence 
 decreased by 20 per cent, and for all forms of violence there was a decrease 
 in mortality of only 5.5 per cent. 
 
 1,000 
 
 '- GRAND TOTAL 
 
 — - SUICIDES 
 
 - HOMICIDES 
 
 - TOTAL - SUICIDES AND HOMICIDES 
 
 - DR OWNINGS 
 
 - OTHER ACCIDENTS 
 
 .— TOTAL DPOWN/UOS AND OTHER ACCIDENTS 
 
 8 loo 
 
 / U - 1 - 1 - 1 - 1 - 1 - 1 - 1 - 1 - 1 - ! - 
 
 Id IE 20 JO AO SO 60 70 DO SO 1900 10 20 
 
 YEAR 
 
 Graph 32 (from table 123). Crude mortality-rates from different types of 
 violence, averaged by 10-year periods, from 1812 to 1920, inclusive. 
 
Chapter XVII. —Child-Birth. 
 
 (Tables 124 to 127, graphs 33 to 34.) 
 
 Deaths from this group of causes were recorded under the single rubric, 
 “ childbed,” until 1875, when those from puerperal fever were classified 
 under a new rubric of that title. Since the adoption of the international 
 classification in 1899, deaths of women from causes connected with child¬ 
 birth have been classified under the eight rubrics, 134 to 141, of this statisti¬ 
 cal nosology. From the relatively small number of deaths ascribed to child¬ 
 bed in the earlier years, it is perhaps fair to assume that the assignments of 
 deaths under this rubric was specific, that is, restricted to deaths of mothers 
 due to causes connected with giving birth to children, and did not include 
 deaths of lying-in women from general causes. Indeed, it is not unlikely that 
 the term was used in a narrower sense than is now the custom, to embrace only 
 deaths of women from causes immediately connected with giving birth to 
 children, living or still, of viable age. 
 
 In the discussion of natality it has been made clear that before 1915 births 
 were not reported with sufficient accuracy for the calculation on this basis of 
 reliable rates of maternal risks in child-bearing. Nor, owing to the uncer¬ 
 tainties connected with estimating in this heterogeneous population from year 
 to year over so long a period, the number of women of the usual child-bearing 
 age (15 to 50 years), is it practicable to calculate rates on the basis next in 
 order of specificity. Consequently, for the years 1812 to 1914, inclusive, 
 maternal mortality from child-bearing must be measured either in terms of 
 the female or of the whole population. Rates calculated on these bases are 
 given in table 124, graph 33. The following discussion of the puerperal mor¬ 
 tality will be confined to the former. It will be observed that these rates often 
 vary not only from year to year, but over long series of years. Rates over 100 
 obtained in years so widely separated as 1816 and 1872. Rates over 80 pre¬ 
 vailed in a number of years. As the other extreme, rates under 35 occurred 
 in both early and recent years, in some years of the third, fourth, fifth, 
 sixth, seventh, and tenth decades of the nineteenth century, and frequently 
 after 1900. Fluctuations from very high to very low rates, and vice versa, did 
 not occur during short periods of 2 or 3 years, but the transition to opposite 
 levels was usually gradual. 
 
 Taking as a convenient basis of comparison the rates averaged for 5-year 
 periods (table 125, graph 34), several distinct waves of high mortality are 
 evident. After remaining on a level of about 70 from 1812 to 1825, during 
 the next 5 years the averaged rate declined to 40. Following a slight reaction 
 to 51 between 1831 and 1835, the rate declined for 10 years and reached the 
 comparatively low level of 37 during the 5 years ending in 1845. Rebounding 
 to 69 during the next quinquennium, the rate attained 80 between 1851-1855. 
 Another abrupt decline brought the rate to 43 in the period ending in 1865. 
 This wave was immediately succeeded by a second of very similar proportions, 
 with a peak-rate of 79 between 1871 and 1875 and with a decline to 37 in the 
 next 5-year period. The fluctuations were comparatively slight between 1881 
 
 487 
 
488 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 Table 124 .—Number of deaths and rate of death, per 100,000 living inhabitants and 
 100,000 living female inhabitants, from causes connected with child-birth, from 1812 
 to 1920, inclusive. 
 
 Year. 
 
 Child-bed. 
 
 Puerperal fever. 
 
 Total. 
 
 Deaths. 
 
 Rate per 
 
 100,000 total 
 population. 
 
 Rate per 
 
 100,000 female 
 
 population. 
 
 Deaths- 
 
 Rate per 
 
 100,000 total 
 
 population. 
 
 Rate per 
 
 100,000 female 
 
 population. 
 
 Deaths- 
 
 Rate per 
 
 100,000 total 
 
 population. 
 
 Rate per 
 
 100,000 female 
 
 population. 
 
 1812 . 
 
 
 
 
 
 
 
 10 
 
 26 
 
 49 
 
 1813 . 
 
 
 
 
 
 
 
 16 
 
 37 
 
 74 
 
 1814 . 
 
 
 
 
 
 
 
 15 
 
 34 
 
 66 
 
 1815 . 
 
 
 
 
 
 
 
 22 
 
 47 
 
 93 
 
 1816 . 
 
 
 
 
 
 
 
 26 
 
 53 
 
 104 
 
 1817 . 
 
 
 
 
 
 
 
 14 
 
 27 
 
 54 
 
 1818 . 
 
 
 
 
 
 
 
 19 
 
 36 
 
 70 
 
 1819 . 
 
 
 
 
 
 
 
 18 
 
 32 
 
 63 
 
 1820 . 
 
 
 
 
 
 
 
 20 
 
 35 
 
 67 
 
 1821 . 
 
 
 
 
 
 
 
 24 
 
 40 
 
 77 
 
 1822 . 
 
 
 
 
 
 
 
 22 
 
 35 
 
 68 
 
 1823 . 
 
 
 
 
 
 
 
 28 
 
 43 
 
 82 
 
 1824 . 
 
 
 
 
 (2) 
 
 (3) 
 
 
 18 
 
 26 
 
 51 
 
 1825 . 
 
 
 
 
 
 
 
 22 
 
 31 
 
 60 
 
 1826 . 
 
 
 
 
 
 
 
 20 
 
 27 
 
 52 
 
 1827 . 
 
 
 
 
 
 
 
 15 
 
 20 
 
 37 
 
 1828 . 
 
 
 
 
 
 
 
 19 
 
 24 
 
 46 
 
 1829 . 
 
 
 
 
 
 
 
 13 
 
 16 
 
 30 
 
 1830 . 
 
 
 
 
 
 
 
 16 
 
 19 
 
 36 
 
 1831 . 
 
 
 
 
 
 
 
 24 
 
 27 
 
 51 
 
 1832 . 
 
 
 
 
 
 
 
 33 
 
 36 
 
 68 
 
 1833 . 
 
 
 
 
 
 
 
 25 
 
 26 
 
 50 
 
 1834 . 
 
 
 
 
 
 
 
 24 
 
 24 
 
 46 
 
 1835 . 
 
 
 
 
 
 
 
 21 
 
 21 
 
 39 
 
 1836 . 
 
 
 
 
 
 
 
 18 
 
 17 
 
 32 
 
 1837 . 
 
 
 
 
 
 
 
 29 
 
 26 
 
 50 
 
 1838 . 
 
 
 
 
 
 
 
 28 
 
 25 
 
 47 
 
 1839 . 
 
 
 
 
 
 
 
 21 
 
 18 
 
 34 
 
 1840 . 
 
 
 
 
 
 
 
 20 
 
 17 
 
 31 
 
 1841 . 
 
 
 
 
 
 
 
 31 
 
 25 
 
 47 
 
 1842 . 
 
 
 
 
 
 
 
 14 
 
 11 
 
 21 
 
 1843 . 
 
 
 
 
 
 
 
 21 
 
 16 
 
 30 
 
 1844 . 
 
 
 
 
 
 
 
 29 
 
 21 
 
 40 
 
 1845 . 
 
 
 
 
 
 
 
 34 
 
 24 
 
 45 
 
 1846 . 
 
 
 
 
 
 
 
 36 
 
 25 
 
 47 
 
 1847 . 
 
 
 
 
 
 
 
 35 
 
 23 
 
 44 
 
 1848 . 
 
 
 
 
 
 
 
 62 
 
 40 
 
 76 
 
 1849 . 
 
 
 
 
 
 
 
 78 
 
 49 
 
 93 
 
 1850 . 
 
 
 
 
 
 
 
 75 
 
 46 
 
 87 
 
 1851 . 
 
 
 
 
 
 
 
 70 
 
 42 
 
 78 
 
 1852 . 
 
 
 
 
 
 
 
 83 
 
 48 
 
 91 
 
 1853 . 
 
 
 
 
 
 
 
 65 
 
 36 
 
 69 
 
 1854 . 
 
 
 
 
 
 
 
 71 
 
 39 
 
 73 
 
 1855 . 
 
 
 
 
 
 
 
 90 
 
 48 
 
 90 
 
 1856 . 
 
 
 
 
 
 
 
 72 
 
 37 
 
 70 
 
 1857 . 
 
 
 
 
 
 
 
 62 
 
 31 
 
 59 
 
 1858 . 
 
 
 
 
 
 
 
 63 
 
 31 
 
 59 
 
 1859 . 
 
 
 
 
 
 
 
 46 
 
 22 
 
 42 
 
 1860 . 
 
 
 
 
 
 
 
 64 
 
 30 
 
 56 
 
 1861 . 
 
 
 
 
 
 
 
 59 
 
 27 
 
 51 
 
 1862 . 
 
 
 
 
 
 
 
 43 
 
 19 
 
 36 
 
 1863 . 
 
 
 
 
 
 
 
 64 
 
 28 
 
 52 
 
 1864 . 
 
 
 
 
 
 
 
 46 
 
 19 
 
 37 
 
 1865 . 
 
 
 
 
 
 
 
 47 
 
 19 
 
 37 
 
 1866 . 
 
 
 
 
 
 
 
 43 
 
 17 
 
 33 
 
MISCELLANEOUS CAUSES OF DEATH 
 
 489 
 
 Table 124. —Number of deaths and rate of death, per 100,000 living inhabitants, 
 
 etc. —Continued. 
 
 
 Year. 
 
 Child-bed. 
 
 Puerperal fever. 
 
 Total. 
 
 i 
 
 Deaths. 
 
 Rate per 
 
 100,000 total 
 population. 
 
 Rate per 
 
 100.000 female 
 
 population. 
 
 Deaths. 
 
 Rate per 
 
 100,000 total 
 
 population. 
 
 Rate per 
 
 100,000 female 
 
 population. 
 
 Deaths- 
 
 Rate per 
 
 100,000 total 
 
 population. 
 
 Rate per 
 
 100,000 female 
 
 population. 
 
 1867 . 
 
 
 
 
 
 
 
 84 
 
 33 
 
 63 
 
 1868 . 
 
 
 
 
 
 
 
 94 
 
 36 
 
 68 
 
 1869 . 
 
 
 
 
 
 
 
 113 
 
 42 
 
 80 
 
 1870 . 
 
 
 
 
 
 
 
 129 
 
 47 
 
 90 
 
 1871 . 
 
 
 
 
 
 
 
 146 
 
 52 
 
 99 
 
 1872 . 
 
 
 
 
 
 
 
 166 
 
 58 
 
 111 
 
 1873 . 
 
 
 
 
 
 
 
 113 
 
 39 
 
 74 
 
 1874 . 
 
 
 
 
 
 
 
 113 
 
 38 
 
 72 
 
 1875 . 
 
 35 
 
 8 
 
 22 
 
 25 
 
 6 
 
 16 
 
 60 
 
 14 
 
 37 
 
 1876 . 
 
 35 
 
 11 
 
 21 
 
 13 
 
 4 
 
 8 
 
 48 
 
 15 
 
 29 
 
 1877 . 
 
 31 
 
 10 
 
 19 
 
 28 
 
 9 
 
 17 
 
 59 
 
 19 
 
 35 
 
 1878 . 
 
 32 
 
 10 
 
 19 
 
 26 
 
 8 
 
 15 
 
 58 
 
 18 
 
 34 
 
 1879 . 
 
 48 
 
 14 
 
 28 
 
 19 
 
 6 
 
 11 
 
 67 
 
 20 
 
 38 
 
 1880 . 
 
 43 
 
 13 
 
 24 
 
 40 
 
 12 
 
 22 
 
 83 
 
 25 
 
 47 
 
 1881 . 
 
 41 
 
 12 
 
 23 
 
 25 
 
 7 
 
 14 
 
 66 
 
 19 
 
 36 
 
 1882 . 
 
 49 
 
 14 
 
 26 
 
 38 
 
 11 
 
 21 
 
 87 
 
 25 
 
 47 
 
 1883 . 
 
 41 
 
 11 
 
 22 
 
 41 
 
 11 
 
 22 
 
 82 
 
 23 
 
 43 
 
 1884 . 
 
 52 
 
 14 
 
 27 
 
 44 
 
 12 
 
 23 
 
 96 
 
 26 
 
 50 
 
 1885 . 
 
 49 
 
 13 
 
 25 
 
 48 
 
 13 
 
 24 
 
 97 
 
 26 
 
 49 
 
 1886 . 
 
 56 
 
 15 
 
 28 
 
 55 
 
 14 
 
 27 
 
 111 
 
 29 
 
 55 
 
 1887 . 
 
 42 
 
 11 
 
 19 
 
 53 
 
 14 
 
 24 
 
 95 
 
 24 
 
 43 
 
 1888 . 
 
 45 
 
 11 
 
 20 
 
 52 
 
 12 
 
 23 
 
 97 
 
 23 
 
 44 
 
 1889 . 
 
 48 
 
 11 
 
 21 
 
 39 
 
 9 
 
 17 
 
 87 
 
 20 
 
 39 
 
 1890 . 
 
 62 
 
 14 
 
 27 
 
 34 
 
 8 
 
 15 
 
 96 
 
 22 
 
 42 
 
 1891 . 
 
 66 
 
 15 
 
 28 
 
 52 
 
 12 
 
 22 
 
 118 
 
 27 
 
 51 
 
 1892 . 
 
 60 
 
 13 
 
 25 
 
 54 
 
 12 
 
 23 
 
 114 
 
 25 
 
 48 
 
 1893 . 
 
 60 
 
 13 
 
 25 
 
 78 
 
 17 
 
 32 
 
 138 
 
 30 
 
 57 
 
 1894 . 
 
 52 
 
 11 
 
 21 
 
 40 
 
 9 
 
 16 
 
 92 
 
 20 
 
 38 
 
 1895 . 
 
 43 
 
 9 
 
 17 
 
 66 
 
 14 
 
 27 
 
 109 
 
 23 
 
 44 
 
 1896 . 
 
 63 
 
 13 
 
 25 
 
 54 
 
 11 
 
 22 
 
 117 
 
 24 
 
 47 
 
 1897 . 
 
 41 
 
 8 
 
 16 
 
 34 
 
 7 
 
 13 
 
 75 
 
 15 
 
 29 
 
 1898 . 
 
 43 
 
 9 
 
 17 
 
 22 
 
 4 
 
 9 
 
 65 
 
 13 
 
 25 
 
 1899 . 
 
 81 
 
 16 
 
 31 
 
 27 
 
 5 
 
 10 
 
 108 
 
 22 
 
 41 
 
 1900 . 
 
 95 
 
 19 
 
 36 
 
 31 
 
 6 
 
 12 
 
 126 
 
 25 
 
 48 
 
 1901 . 
 
 71 
 
 14 
 
 27 
 
 55 
 
 11 
 
 21 
 
 126 
 
 25 
 
 47 
 
 1902 . 
 
 55 
 
 11 
 
 20 
 
 62 
 
 12 
 
 23 
 
 117 
 
 22 
 
 43 
 
 1903 . 
 
 53 
 
 10 
 
 19 
 
 58 
 
 11 
 
 21 
 
 111 
 
 21 
 
 40 
 
 1904 . 
 
 47 
 
 9 
 
 17 
 
 59 
 
 11 
 
 21 
 
 106 
 
 20 
 
 38 
 
 1905 . 
 
 46 
 
 9 
 
 16 
 
 56 
 
 10 
 
 20 
 
 102 
 
 19 
 
 36 
 
 1906 . 
 
 59 
 
 11 
 
 21 
 
 43 
 
 8 
 
 15 
 
 102 
 
 19 
 
 36 
 
 1907 . 
 
 44 
 
 8 
 
 15 
 
 43 
 
 8 
 
 15 
 
 87 
 
 16 
 
 30 
 
 1908 . 
 
 47 
 
 8 
 
 16 
 
 45 
 
 8 
 
 16 
 
 92 
 
 16 
 
 32 
 
 1909 . 
 
 66 
 
 12 
 
 23 
 
 37 
 
 7 
 
 13 
 
 103 
 
 18 
 
 35 
 
 1910 . 
 
 59 
 
 10 
 
 20 
 
 27 
 
 5 
 
 9 
 
 86 
 
 15 
 
 29 
 
 1911 . 
 
 54 
 
 9 
 
 18 
 
 33 
 
 6 
 
 11 
 
 87 
 
 15 
 
 29 
 
 1912 . 
 
 62 
 
 11 
 
 21 
 
 43 
 
 7 
 
 14 
 
 105 
 
 18 
 
 35 
 
 1913 . 
 
 63 
 
 11 
 
 21 
 
 49 
 
 8 
 
 16 
 
 112 
 
 19 
 
 37 
 
 1914 . 
 
 49 
 
 8 
 
 16 
 
 35 
 
 6 
 
 11 
 
 84 
 
 14 
 
 27 
 
 1915 . 
 
 55 
 
 9 
 
 18 
 
 25 
 
 4 
 
 8 
 
 80 
 
 13 
 
 26 
 
 1916 . 
 
 69 
 
 11 
 
 22 
 
 35 
 
 6 
 
 11 
 
 104 
 
 17 
 
 33 
 
 1917 . 
 
 57 
 
 9 
 
 18 
 
 34 
 
 6 
 
 11 
 
 91 
 
 15 
 
 29 
 
 1918 . 
 
 88 
 
 14 
 
 28 
 
 31 
 
 5 
 
 10 
 
 119 
 
 19 
 
 38 
 
 1919 . 
 
 103 
 
 14 
 
 28 
 
 40 
 
 6 
 
 11 
 
 143 
 
 20 
 
 39 
 
 1920 . 
 
 93 
 
 13 
 
 25 
 
 40 
 
 5 
 
 11 
 
 133 
 
 18 
 
 36 
 
490 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 Graph 33 (from table 124). Mortality-rates, per 100,000 living female 
 inhabitants, from causes connected with child-birth, from 1812 to 1920, 
 inclusive. 
 
 Table 125. — Average rate of death, per 100,000 living inhabitants and per 100,000 living 
 female inhabitants, by 5-year periods, from causes connected with child-birth, 
 from 1812 to 1920, inclusive. 
 
 Periods. 
 
 Child-bed. 
 
 Puerperal fever. 
 
 Total. 
 
 Total • 
 population. 
 
 Female 
 
 population. 
 
 Total 
 
 population. 
 
 Female 
 
 population. 
 
 Total 
 
 population. 
 
 Female 
 
 population. 
 
 1812-15 . 
 
 
 
 
 
 36 
 
 70 
 
 1816-20 . 
 
 
 
 
 
 37 
 
 72 
 
 1821-25 . 
 
 
 
 
 
 35 
 
 67 
 
 1826-30 . 
 
 
 
 
 
 21 
 
 40 
 
 1831-35 . 
 
 
 
 
 
 27 
 
 51 
 
 1836-40 . 
 
 
 
 
 
 21 
 
 39 
 
 1841-45 . 
 
 
 
 
 
 19 
 
 37 
 
 1846-50 . 
 
 
 
 
 
 27 
 
 69 
 
 1851-55 . 
 
 
 
 
 
 42 
 
 80 
 
 1856-60 . 
 
 
 
 
 
 30 
 
 57 
 
 1861-65 . 
 
 
 
 
 
 22 
 
 43 
 
 1866-70 . 
 
 
 
 
 
 35 
 
 67 
 
 1871-75 . 
 
 
 
 
 
 39 
 
 79 
 
 1876-80 . 
 
 12 
 
 22 
 
 8 
 
 15 
 
 19 
 
 37 
 
 1881-85 . 
 
 13 
 
 25 
 
 11 
 
 21 
 
 24 
 
 45 
 
 1886-90 . 
 
 12 
 
 23 
 
 11 
 
 21 
 
 24 
 
 45 
 
 1891-95 . 
 
 12 
 
 23 
 
 13 
 
 24 
 
 25 
 
 48 
 
 1896-1900 . 
 
 13 
 
 25 
 
 7 
 
 13 
 
 20 
 
 38 
 
 1901-05 . 
 
 10 
 
 20 
 
 11 
 
 21 
 
 21 
 
 41 
 
 1906-10 . 
 
 10 
 
 19 
 
 7 
 
 14 
 
 17 
 
 33 
 
 1911-15 . 
 
 10 
 
 19 
 
 6 
 
 12 
 
 16 
 
 31 
 
 1916-20 . 
 
 12 
 
 24 
 
 5 
 
 11 
 
 18 
 
 35 
 
MISCELLANEOUS CAUSES OF DEATH 
 
 491 
 
 and 1905. During the remainder of the period the rate was 33 from 1906 
 to 1910, 31 from 1911 to 1915, and 35 from 1916 to 1920. The two high 
 waves which occurred between 1846 and 1880 culminated with a rate on a 
 level with that which obtained in 1841-1845 and which was not bettered in 
 any subsequent period until 1906-1910. 
 
 Kates for puerperal fever and for all other causes combined, for which sep¬ 
 arate data exist since 1875 (tables 124 and 125, graphs 33 and 34), run 
 quite different courses. As averaged for 5-year periods the rate for other 
 causes of maternal deaths follows a fairly even course. During the whole 
 term this rate varied only between 25 and 19 and the level was nearly the 
 same in the first and the last 5-year periods. In strong contrast with this com- 
 
 Graph 34 (from table 125). Mortality-rates, per 100,000 living female 
 inhabitants, from causes connected with child-birth, averaged by 5-year 
 periods, from 1812 to 1920, inclusive. 
 
 parative stability, the rate for puerperal fever varied from 15 in 1875-1880 
 and 24 in 1891-1895 to 11 in 1916-1920. 
 
 There were two very distinct high waves of mortality, one between 1876 
 and 1895 and the other between 1901 and 1905. From the last peak which 
 was attained in the period 1901-1905, the rate declined continuously, and in 
 the period 1916-1920 it stood at its lowest recorded level. These two con¬ 
 siderable waves of high mortality from puerperal fever correspond with similar 
 though relatively slight changes in the total rate. In so far as may be judged 
 from rates so crude, this picture suggests that puerperal fever, like other 
 infectious diseases, has run in epidemic course and that this affection was the 
 chief factor in the earlier high waves of total child-bed mortality. 
 
 It has been recently pointed out by the writer (66) that annual rates calcu¬ 
 lated from the sum of the recorded living and still-births and the number 
 32 
 
492 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 of deaths of women classified under affections of the puerperal state (rubrics 
 134 to 141, inclusive) express in terms more nearly specific than those com¬ 
 monly relied on the actual risk of death of women definitely exposed in 
 child-bearing. Expressed in formal terms the true maternal risk-rate in 
 child-bearing is derived from the formula 
 
 DP 
 
 n j) _ _ 
 
 ~ BL + B8 
 
 where DP equals the number of maternal deaths due to causes definitely con¬ 
 nected with the puerperal state and BL and BS equal the number of live and 
 still-births, respectively. It was recognized that, while far more accurate than 
 those in common use, owing to certain defects in the divisor connected with 
 the definition of still-births and in the dividend resulting from errors in the 
 nosological classification of maternal deaths, even this method cannot be 
 expected in actual practice to measure with absolute accuracy the risk to 
 mothers in child-bearing, nor to yield figures which for different places are 
 strictly comparable. 
 
 The term still-birth is variously defined in different countries and in dif¬ 
 ferent localities in the same country, from early embryos to full-term chil¬ 
 dren born alive, but not surviving the third day of extra-uterine life. The 
 mean between those extremes, in most countries at least, is represented by a 
 dead-born fetus of that age-period of utero-gestation at which, if liveborn, 
 extra-uterine existence is possible, or, in other words, a dead-born fetus past 
 the sixth month after conception. After consideration of available data, the 
 conclusion was reached that in 1918 for the United States birth registration 
 area as a whole, the number of still-births reported represented the actual num¬ 
 ber of fetuses of 5 months and over of utero-gestation born dead. It was found 
 that for this year in the United States registration area the proportion of 
 instances of plural to single births was approximately 1 per cent. As the 
 reporting of live births is complete nowhere in the United States, it was 
 thought inadvisable in general studies based on the natality figures of this 
 country to apply this obvious correction. The inclusion of still-births in the 
 divisor is demanded on medical as well as on statistical grounds, for many of the 
 factors which cause the death of the unborn child, or which accompany or fol¬ 
 low birth of a still-born child, actually increase the maternal risks. 
 
 The dividend, which embraces the deaths classified under rubrics 134 to 
 141, inclusive, is open to certain obvious, but usually overlooked, errors. While 
 these rubrics are specific in the sense that they do not include deaths occurring 
 in pregnant women due to ordinary causes, such as communicable diseases 
 (puerperal infection excepted) and cardio-renal disease, for instance, some of 
 them are not specific for the present purpose. To six of the eight rubrics, acci¬ 
 dents of pregnancy (134), puerperal hemorrhage (135), accidents of labor 
 (136), puerperal septicemia (137), puerperal albuminuria and convulsions 
 (138), and phlegmasia and alba dolens (139), are credited some deaths of 
 women from these causes occurring in all stages of the pregnant and puerperal 
 states from conception to weeks after the completion of labor. Accidents of 
 pregnancy include maternal deaths due to accidental abortions, miscarriages, 
 extra-uterine pregnancy, and vomiting of pregnancy occurring in the early 
 months of gestation. Puerperal hemorrhage, toxemias, and convulsions, puer- 
 
MISCELLANEOUS CAUSES OF DEATH 
 
 493 
 
 peral infection (after abortions and miscarriages), deformities of mother or 
 child, injuries and operations, and any of the vascular lesions enumerated 
 under rubric 139, may be fatal before the end of the fifth month of pregnancy. 
 
 All except two and all the important rubrics include some maternal deaths 
 occurring at any time during the pregnant state, and therefore represent not 
 with strict accuracy but only approximately the number of deaths from these 
 causes of women 5 months pregnant and over. These rubrics were set up on 
 the principle of measuring the deaths of the whole pregnant state. On the 
 other hand, by the consensus of opinion, child-birth, or labor, has been 
 restricted to the act of bringing into the extra-uterine world fetuses of at 
 least 5 months of utero-gestation. Therefore, to obtain maternal risk-rates 
 strictly specific for the act of child-birth, where the divisor consists of the total 
 number of living and still-born children above this arbitrarily fixed stage of 
 development, the dividend should include only those maternal deaths which 
 occur in connection with the horning of children after the completion of the 
 fifth month of pregnancy. To determine the risk of death to women of becom¬ 
 ing pregnant, that is, from conception to several weeks after expulsion of 
 the living or dead impregnated ovum of whatever period of development, is 
 impossible. The number of deaths under these eight rubrics under discussion 
 furnish the dividend, but there are lacking the correct figures for the divisor, 
 which embrace not only the births of fetuses over the fifth month of gesta- 
 tation, but the large and entirely unknown number of miscarriages and of 
 recognized and unrecognized abortions. 
 
 It is evident, then, that from the recorded data it is impossible to calculate 
 with absolute accuracy the risk to women of either pregnancy or of child-birth. 
 For determining the risk of death in child-birth there are in both divisor and 
 dividend certain relatively minor errors for which, under methods by wlich 
 the data are collected and recorded, fitting allowances for correction can not 
 be made. It is clear, however, that the method here employed must measure 
 much more accurately than any of those in general use the risk to women of 
 dying from causes connected with child-birth. 
 
 For the 6-year period 1915 to 1920, the living and still-births have been 
 reported with sufficient accuracy for the calculation on the basis above out¬ 
 lined of specific maternal risk-rates of deaths connected with child-birth. The 
 data are presented in table 126. Considering first the total population, that is, 
 whites and negroes together, it will be noticed that the rate for all causes in 
 the puerperal state not only reached the very high average level of 646, but 
 actually rose during the period under consideration from 542 in 1915 to 659 in 
 1920, with even higher rates in 1918 and 1919. Puerperal infection, with an 
 average rate of 197, was responsible for 30 per cent of the deaths from this 
 group of causes. Puerperal albuminuria and convulsions ranked next and rose 
 to a level almost as high. The rates for accidents of pregnancy varied con¬ 
 siderably from year to year, and with an average rate of 101 and average per¬ 
 centage of the whole number of deaths of 15.8, stood third in order of fatality. 
 Puerperal hemorrhage and accidents of labor, which also showed marked 
 annual fluctuations with averaged rates of 75 and 67, respectively, were of 
 about equal lethal force. No deaths were ascribed to rubrics 140 and 141. 
 The fatality of the puerperal affections in whites and in negroes may be com¬ 
 pared for 1919 and 1920. Taking the average for the two years it is to be 
 
494 
 
 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
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 * Since no deaths were recorded under the headings “ Following Child-birth,” and “ Puerperal diseases of the breast,” these two rubrics (Nos. 140 and 141) are 
 omitted from the table. 
 
MISCELLANEOUS CAUSES OF DEATH 
 
 495 
 
 observed that the rate in negroes for the whole puerperal state was nearly 
 double and for puerperal fever more than double those for whites. The rates 
 were considerably higher in negro than in white women for every rubric 
 under which deaths were recorded, with the exception of those for accidents 
 of pregnancy and vascular affections. The importance of taking still-births 
 into account in calculating puerperal risk-rates is very obvious from this table. 
 Were they omitted, the divisors would be too small for the population as a 
 whole by 7.4 per cent and for white and for negro women by 5.9 and 12.8 
 per cent, respectively, with corresponding errors in the resulting rates. 
 
 During the 6-year period 1915-1920, of 101,539 conceptions that developed 
 to or beyond the sixth month of utero-gestation, 7,558, or 7.4 per cent, were 
 blighted, and of approximately the same number of women exposed under 
 the same conditions to the risks of maternity there died 670 or 0.65 per 
 hundred. This combination of appallingly high rates of both maternal and 
 fetal mortality has been equaled perhaps in modern times in no other medi¬ 
 cal center. In the United States birth registration area in 1918 and in Boston 
 in recent years, the maternal death-rates were considerably higher, but they 
 were associated with still-birth rates not half so high (Howard, 66). 
 
 Having determined the approximately true maternal risk of death in child- 
 bearing during the period in which it appears that births (living and still) 
 were reported with a reasonable degree of completeness, attention may now be 
 turned to the consideration of rates calculated on less reliable birth data, for 
 the period between 1875 and 1914, with the expectation that when compared 
 with the rates based upon the whole female population it may be possible 
 to form a more exact estimate than hitherto possible of the course of maternal 
 mortality during this period. The courses of the rates calculated on these two 
 bases (tables 124 and 127) show very distinct correspondences. From both is 
 evident that there were very marked increases in the rates for puerperal fever 
 between 1881 and 1889, 1891 and 1896, and 1901 and 1905. It is also clearly 
 shown that the mortality for all other causes ran a much less uneven course 
 than did that for puerperal fever. It would appear, then, that, while in the 
 intermediate period the rates from causes connected with child-birth had risen 
 to much higher levels, the rates were on the whole but little lower in 1915- 
 1920 than in 1875-1880. What gain there was affected puerperal fever chiefly. 
 The latter has been declining since about 1900. 
 
 Any attempt to correlate the course of child-bed mortality over the long 
 period under review with the various factors known to influence it is beset 
 with many difficulties. Of prime importance is the relative crudity of the 
 rates on which its measurement must be based. In this regard, changes in the 
 age distribution of the female population, race composition, opportunities for 
 marriage, variations in the proportions of legitimate and illegitimate births, 
 and those fluctuations in birth-rates which are dependent upon so many other 
 social circumstances, as well as upon the occurrence of epidemics, and which 
 therefore chiefly determined the number exposed to risk, are all left out of 
 consideration. From the standard of measurement available, it appears that 
 maternal mortality in child-bed has run in rather definite waves and that since 
 1875, while to some extent these waves and their peaks have been associated 
 with variations in the mortality from causes other than puerperal fever, on 
 the whole they have been influenced to a much greater degree by rises and 
 declines in the rate of the latter cause. Since in the past 20 years, when the 
 
496 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 birth-rate has probably varied within narrow limits, the rate from puerperal 
 fever has shown a perceptible decline and the rate for other causes on the 
 whole has fallen but slightly, it seems likely that the very distinct waves of 
 
 Table 127 .—Number of deaths and rate of death, per 100,000 recorded births, living and 
 still, from causes connected with child-birth, from 1875 to 1920, inclusive. 
 
 D — death. R = rate. 
 
 Year. 
 
 Total puerperal 
 state. 
 
 Puerperal septicemia. 
 
 Total puerperal state excluding 
 puerperal septicemia. 
 
 D 
 
 R 
 
 D 
 
 R 
 
 Per cent of 
 total puerperal 
 state. 
 
 D 
 
 R 
 
 Per cent of 
 total puerperal 
 state. 
 
 1875 . 
 
 60 
 
 687 
 
 25 
 
 286 
 
 41.7 
 
 35 
 
 401 
 
 58.3 
 
 1876 . 
 
 48 
 
 612 
 
 13 
 
 166 
 
 27.1 
 
 35 
 
 447 
 
 72.9 
 
 1877 . 
 
 59 
 
 826 
 
 28 
 
 392 
 
 47.5 
 
 31 
 
 434 
 
 52.5 
 
 1878 . 
 
 58 
 
 864 
 
 26 
 
 387 
 
 44.8 
 
 32 
 
 477 
 
 55.2 
 
 1879 . 
 
 67 
 
 814 
 
 19 
 
 231 
 
 28.4 
 
 48 
 
 583 
 
 71.6 
 
 1880 . 
 
 83 
 
 877 
 
 40 
 
 423 
 
 48.2 
 
 43 
 
 454 
 
 51.8 
 
 1881 . 
 
 66 
 
 721 
 
 25 
 
 273 
 
 37.9 
 
 41 
 
 448 
 
 62.1 
 
 1882 . 
 
 87 
 
 1031 
 
 38 
 
 450 
 
 43.7 
 
 49 
 
 581 
 
 56.3 
 
 1883 . 
 
 82 
 
 953 
 
 41 
 
 476 
 
 50.0 
 
 41 
 
 476 
 
 50.0 
 
 1884 . 
 
 96 
 
 1081 
 
 44 
 
 495 
 
 45.8 
 
 52 
 
 586 
 
 54.2 
 
 1885 . 
 
 97 
 
 1156 
 
 48 
 
 572 
 
 49.5 
 
 49 
 
 584 
 
 50.5 
 
 1886 . 
 
 111 
 
 1319 
 
 55 
 
 654 
 
 49.5 
 
 56 
 
 665 
 
 50.5 
 
 1887 . 
 
 95 
 
 977 
 
 53 
 
 545 
 
 55.8 
 
 42 
 
 432 
 
 44.2 
 
 1888 . 
 
 97 
 
 1030 
 
 52 
 
 552 
 
 53.6 
 
 45 
 
 478 
 
 46.4 
 
 1889 . 
 
 87 
 
 857 
 
 39 
 
 384 
 
 44.8 
 
 48 
 
 473 
 
 55.2 
 
 1890 . 
 
 96 
 
 941 
 
 34 
 
 333 
 
 35.4 
 
 62 
 
 608 
 
 64.6 
 
 1891 . 
 
 118 
 
 1163 
 
 52 
 
 512 
 
 44.1 
 
 66 
 
 650 
 
 55.9 
 
 1892 . 
 
 114 
 
 1113 
 
 54 
 
 527 
 
 47.4 
 
 60 
 
 586 
 
 52.6 
 
 1893 . 
 
 138 
 
 1393 
 
 78 
 
 787 
 
 56.5 
 
 60 
 
 606 
 
 43.5 
 
 1894 . 
 
 92 
 
 911 
 
 40 
 
 396 
 
 43.5 
 
 52 
 
 515 
 
 56.5 
 
 1895 . 
 
 109 
 
 1249 
 
 66 
 
 756 
 
 60.6 
 
 43 
 
 493 
 
 39.4 
 
 1896 . 
 
 117 
 
 1235 
 
 54 
 
 570 
 
 46.2 
 
 63 
 
 665 
 
 53.8 
 
 1897 . 
 
 75 
 
 789 
 
 34 
 
 358 
 
 45.3 
 
 41 
 
 431 
 
 54.7 
 
 1898 . 
 
 65 
 
 681 
 
 22 
 
 231 
 
 33.8 
 
 43 
 
 451 
 
 66.2 
 
 1899 . 
 
 108 
 
 1236 
 
 27 
 
 309 
 
 25.0 
 
 81 
 
 927 
 
 75.0 
 
 1900 . 
 
 126 
 
 1350 
 
 31 
 
 332 
 
 24.6 
 
 95 
 
 1018 
 
 75.4 
 
 1901 . 
 
 126 
 
 1331 
 
 55 
 
 581 
 
 43.6 
 
 71 
 
 750 
 
 56.4 
 
 1902 . 
 
 117 
 
 1227 
 
 62 
 
 645 
 
 53.0 
 
 55 
 
 572 
 
 47.0 
 
 1903 . 
 
 111 
 
 1186 
 
 58 
 
 620 
 
 52.3 
 
 53 
 
 566 
 
 47.7 
 
 1904 . 
 
 106 
 
 1139 
 
 59 
 
 634 
 
 55.7 
 
 47 
 
 505 
 
 44.3 
 
 1905 . 
 
 102 
 
 1045 
 
 56 
 
 573 
 
 54.9 
 
 46 
 
 471 
 
 45.1 
 
 1906 . 
 
 102 
 
 1027 
 
 43 
 
 433 
 
 42.2 
 
 59 
 
 594 
 
 57.8 
 
 1907 . 
 
 87 
 
 911 
 
 43 
 
 450 
 
 49.5 
 
 44 
 
 460 
 
 50.5 
 
 1908 . 
 
 92 
 
 921 
 
 45 
 
 450 
 
 48.9 
 
 47 
 
 471 
 
 51.1 
 
 1909 . 
 
 103 
 
 1071 
 
 37 
 
 385 
 
 35.9 
 
 66 
 
 687 
 
 64.1 
 
 1910 . 
 
 86 
 
 805 
 
 27 
 
 253 
 
 31.4 
 
 59 
 
 552 
 
 68.6 
 
 1911 . 
 
 87 
 
 870 
 
 33 
 
 330 
 
 37.9 
 
 54 
 
 540 
 
 62.1 
 
 1912 . 
 
 105 
 
 869 
 
 43 
 
 356 
 
 41.0 
 
 62 
 
 513 
 
 59.0 
 
 1913 . 
 
 112 
 
 833 
 
 49 
 
 364 
 
 43.7 
 
 63 
 
 468 
 
 56.3 
 
 1914 . 
 
 84 
 
 615 
 
 35 
 
 256 
 
 41.7 
 
 49 
 
 359 
 
 58.3 
 
 1915 . 
 
 80 
 
 542 
 
 25 
 
 169 
 
 31.2 
 
 55 
 
 373 
 
 68.8 
 
 1916 . 
 
 104 
 
 637 
 
 35 
 
 215 
 
 33.7 
 
 69 
 
 423 
 
 66.4 
 
 1917 . 
 
 91 
 
 561 
 
 32 
 
 197 
 
 35.2 
 
 59 
 
 364 
 
 64.8 
 
 1918 . 
 
 119 
 
 722 
 
 31 
 
 188 
 
 26.1 
 
 88 
 
 534 
 
 74.0 
 
 1919 . 
 
 143 
 
 754 
 
 40 
 
 211 
 
 28.0 
 
 103 
 
 543 
 
 72.0 
 
 1920 . 
 
 133 
 
 659 
 
 40 
 
 198 
 
 30.1 
 
 93 
 
 461 
 
 69.9 
 
 child-bed mortality previous to 1875 were associated mainly with variations 
 in the prevalence and severity of puerperal infection. 
 
 In connection with the high wave of mortality in the 10-year period after 
 1845, it is of interest to recall that Buckler recorded that in this period the 
 
MISCELLANEOUS CAUSES OF DEATH 
 
 497 
 
 obstetric ward of the almshouse infirmary was closed a number of times on 
 account of severe epidemics of puerperal fever. This affection was doubtless 
 responsible for a considerable proportion of the high wave of child-bed mor¬ 
 tality at this time as well as in the second, third, fourth, seventh, and eighth 
 decades of the nineteenth century. With the exception of the wave in the 
 fourth and fifth decades just referred to, high death-rates from erysipelas 
 and puerperal fever were not synchronous. The well-known relation between 
 scarlet fever and puerperal infection suggests a comparison in this connec¬ 
 tion. In the period before 1875 high rates for scarlet fever and child-birth 
 sychronized in 1836-1837, 1844-1859, and 1866-1874. Between 1876 and 
 1888 and between 1901 and 1904, rates for scarlet fever and puerperal fever 
 were both relatively high. In view of these coincidences and the established 
 facts of the intimate causal relation between scarlet fever and puerperal infec¬ 
 tion, the inference seems warranted that child-bed mortality in Baltimore has 
 been strongly influenced by these two affections. 
 
 Perhaps in no other medical center in the United States have the extremes 
 of the obstetric art been so well represented as in Baltimore. From the time 
 of Buchanan in the eighteenth century, the city has at no time lacked able 
 and skilled teachers and practitioners of obstetrics. Owing to lack of facilities 
 for practical teaching, and in many instances to the poor material among the 
 students of proprietary schools, a large proportion of the general physicians 
 has been poorly trained in obstetrics. Midwives have flourished since the 
 earliest days. Without schools for instruction and without oversight worthy 
 of the name they have been and are, in general, ignorant and inept in the art. 
 As late as 1920 over 200 were registered as in practice. In 1920, of 18,787 
 living births, 26.1 per cent were attended by midwives. As the percentage of 
 whites was 26.5 and of negroes 23.3, it is evident that the higher maternal 
 mortality in the latter can not be attributed to midwives. Baltimore was 
 fortunate in the absence of lying-in hospitals in the days previous to antisepsis, 
 when obstetric hospitals were often so deadly. With the exception of a few 
 beds at the almshouse infirmary and in not over two hospitals in the city, 
 obstetrical hospitals can hardly have been said to have existed here before the 
 ninth decade of the nineteenth century. At this period lying-in hospitals were 
 established under careful obstetricians in connection with the University of 
 Maryland and other medical schools. In 1895 the obstetrical wards of the 
 Johns Hopkins Hospital were opened. 
 
 While no one of these hospital services has ever been large enough to accom¬ 
 modate more than a small proportion of parturient women, they have been 
 sufficient on the whole to care for all of the serious cases needing hospitaliza¬ 
 tion encountered in the extensive out-patient departments connected with 
 them. According to a conservative estimate, in 1917 about one-fourth of all 
 the deliveries in the city occurred under the care of these institutions, either 
 in the hospitals or in homes, mostly by medical students under competent 
 supervision. To these services, to antisepsis, and to improved opportunities 
 for obstetrical teaching, the decline in the maternal death-rate from causes 
 connected with child-birth is doubtless largely to be attributed. It is evident, 
 from the high maternal and still-birth rates yet obtaining, that obstetrical 
 care of women is far from adequate. The obstetrical clinics established at the 
 'writer’s suggestion under the health department in 1919 have not been devel¬ 
 oped sufficiently to make an impression on the problem. 
 
Chapter XVIII. —Ill-Defined Causes. 
 
 Diseases of early infancy; Arthritis; Hernia and Intestinal obstruction. 
 
 (Tables 128 to 132.) 
 
 DISEASES OF EARLY INFANCY. 
 
 By grouping together under three rubrics the deaths classified under various 
 statistical headings that can be followed for longer or shorter periods in the 
 mortality tables, it is possible to trace in general outline for 100 years the 
 course of mortality from causes peculiar to infancy. These three rubrics are 
 convulsions, marasmus, and causes unknown in infants. The annual rates 
 for these are given in tables 128 and 132, respectively. In regard to age these 
 rates are crude, and in regard to cause they are inexact, for it has been neces¬ 
 sary to use as divisor the total estimated population, and the dividends are 
 subject to errors of both inclusion and omission. It is likely, however, that 
 these have tended to balance each other. These data have been submitted to 
 all possible checks, the most important of which was the critical examination 
 of a large number of the original death certificates of 1875 and other years. 
 Here it was ascertained that, with few exceptions, the deaths certified under 
 the headings included in these rubrics occurred in individuals in the first two 
 years of life and, in the overwhelming majority of instances, in the early 
 months of infancy. The same was found to hold true of the more definitive 
 rubrics into which these various headings finally merged in the international 
 classification in and after 1899. Further justification of the use of these data 
 in this connection will appear from the following analysis: 
 
 CONVULSIONS. 
 
 This rubric (table 128), appearing annually without intermission since 
 1812, was characterized by rates particularly high from 1812 to 1840 and 
 from 1866 to 1892. While it probably included some deaths of infants, of 
 older children, and even of adults with convulsions associated with uraemia, 
 whooping-cough, scarlet fever, and meningitis, from the relative magnitude 
 of the rates in the earlier years it seems improbable that errors from these 
 sources were large. It was apparently synonymous with convulsions of infants 
 (later rubric 71), into which it merged in 1899. 
 
 MARASMUS. 
 
 (Table 128.) 
 
 This term is used for this rubric because it was the first member of this 
 category of causes of death to appear in the statistical nosology. Except for 
 a few years in the fifth decade of the nineteenth century, it was annually 
 credited with a considerable number of deaths from 1820 to 1898, when it dis¬ 
 appeared. Next to appear was debility in 1851. To this heading was ascribed 
 498 
 
Table 128 .—Number o] deaths and rate of death, per 100,000 living inhabitants, from convulsions, ma¬ 
 rasmus, rheumatism and gout, senility, hernia and intestinal obstruction, and appendicitis and ty¬ 
 phlitis, from 1812 to 1920, inclusive. 
 
 D = death. R = rate. 
 
 Year. 
 
 Con¬ 
 
 vulsions. 
 
 Ma¬ 
 
 rasmus.* 
 
 Rheumatism and gout. 
 
 Senility. 
 
 Hernia and 
 intestinal 
 obstruction. 
 
 Appendicitis 
 and typhlitis. 
 
 Chronic 
 
 rheumatism and 
 gout. 
 
 Imfiamma- 
 tory rheuma¬ 
 tism. 
 
 Total. 
 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 1812.. 
 
 64 
 
 156 
 
 
 
 3 
 
 7 
 
 
 
 3 
 
 7 
 
 42 
 
 103 
 
 
 
 
 
 1813.. 
 
 115 
 
 269 
 
 
 
 1 
 
 2 
 
 
 
 1 
 
 2 
 
 62 
 
 145 
 
 
 
 
 
 1814.. 
 
 80 
 
 179 
 
 • • • • 
 
 
 2 
 
 4 
 
 
 
 2 
 
 4 
 
 69 
 
 154 
 
 
 
 
 
 1815.. 
 
 98 
 
 210 
 
 • • • • 
 
 
 2 
 
 4 
 
 
 
 2 
 
 4 
 
 83 
 
 178 
 
 
 
 
 
 1816.. 
 
 91 
 
 186 
 
 • • • • 
 
 
 6 
 
 12 
 
 
 
 6 
 
 12 
 
 54 
 
 111 
 
 
 
 
 
 1817.. 
 
 98 
 
 192 
 
 • • • • 
 
 
 3 
 
 6 
 
 
 
 3 
 
 6 
 
 57 
 
 112 
 
 
 
 
 
 1818.. 
 
 115 
 
 216 
 
 • • • • 
 
 
 1 
 
 2 
 
 
 
 1 
 
 2 
 
 62 
 
 117 
 
 
 
 
 
 1819.. 
 
 92 
 
 166 
 
 • • • • 
 
 
 6 
 
 11 
 
 2 
 
 4 
 
 8 
 
 14 
 
 77 
 
 139 
 
 
 
 
 
 1820.. 
 
 90 
 
 156 
 
 6 
 
 10 
 
 2 
 
 3 
 
 
 
 2 
 
 3 
 
 78 
 
 135 
 
 
 
 
 
 1821.. 
 
 84 
 
 139 
 
 15 
 
 25 
 
 5 
 
 8 
 
 
 
 5 
 
 8 
 
 93 
 
 154 
 
 
 
 
 
 1822.. 
 
 83 
 
 132 
 
 46 
 
 73 
 
 11 
 
 18 
 
 1 
 
 2 
 
 12 
 
 19 
 
 87 
 
 138 
 
 
 
 
 
 1823.. 
 
 60 
 
 92 
 
 13 
 
 20 
 
 9 
 
 14 
 
 
 
 9 
 
 14 
 
 69 
 
 105 
 
 
 
 
 
 1824.. 
 
 46 
 
 68 
 
 1 
 
 1 
 
 4 
 
 6 
 
 
 
 4 
 
 6 
 
 72 
 
 106 
 
 
 
 
 
 1825.. 
 
 47 
 
 66 
 
 35 
 
 49 
 
 2 
 
 3 
 
 
 
 2 
 
 3 
 
 69 
 
 97 
 
 
 
 
 
 1826.. 
 
 55 
 
 75 
 
 10 
 
 14 
 
 4 
 
 5 
 
 1 
 
 1 
 
 5 
 
 7 
 
 107 
 
 145 
 
 
 
 
 
 1827.. 
 
 63 
 
 82 
 
 27 
 
 35 
 
 4 
 
 5 
 
 3 
 
 4 
 
 7 
 
 9 
 
 71 
 
 93 
 
 
 
 
 
 1828.. 
 
 68 
 
 86 
 
 27 
 
 34 
 
 2 
 
 3 
 
 • • • • 
 
 • • • • 
 
 2 
 
 3 
 
 93 
 
 117 
 
 
 
 
 
 1829.. 
 
 68 
 
 82 
 
 89 
 
 108 
 
 3 
 
 4 
 
 • • • • 
 
 • • • • 
 
 3 
 
 4 
 
 107 
 
 130 
 
 
 
 
 
 1830.. 
 
 70 
 
 82 
 
 82 
 
 96 
 
 5 
 
 6 
 
 • • • • 
 
 • • • • 
 
 5 
 
 6 
 
 94 
 
 110 
 
 
 
 
 
 1831.. 
 
 78 
 
 88 
 
 32 
 
 36 
 
 8 
 
 9 
 
 1 
 
 1 
 
 9 
 
 10 
 
 104 
 
 117 
 
 
 
 
 
 1832.. 
 
 89 
 
 97 
 
 55 
 
 60 
 
 7 
 
 8 
 
 1 
 
 1 
 
 8 
 
 9 
 
 164 
 
 178 
 
 
 
 
 
 1833.. 
 
 110 
 
 115 
 
 27 
 
 28 
 
 2 
 
 2 
 
 2 
 
 2 
 
 4 
 
 4 
 
 87 
 
 91 
 
 
 
 
 
 1834.. 
 
 93 
 
 94 
 
 17 
 
 17 
 
 2 
 
 2 
 
 1 
 
 1 
 
 3 
 
 3 
 
 126 
 
 127 
 
 
 
 
 
 1835.. 
 
 89 
 
 87 
 
 30 
 
 29 
 
 2 
 
 2 
 
 • • • • 
 
 • • • • 
 
 2 
 
 2 
 
 120 
 
 117 
 
 
 
 
 
 1836.. 
 
 92 
 
 87 
 
 27 
 
 25 
 
 • • 
 
 • • 
 
 2 
 
 2 
 
 2 
 
 2 
 
 137 
 
 129 
 
 
 
 
 
 1837.. 
 
 90 
 
 82 
 
 32 
 
 29 
 
 7 
 
 6 
 
 • • • • 
 
 • « • • 
 
 7 
 
 6 
 
 93 
 
 85 
 
 
 
 
 
 1838.. 
 
 89 
 
 79 
 
 30 
 
 26 
 
 2 
 
 2 
 
 3 
 
 3 
 
 5 
 
 4 
 
 94 
 
 83 
 
 
 
 
 
 1839.. 
 
 68 
 
 58 
 
 18 
 
 15 
 
 4 
 
 3 
 
 2 
 
 2 
 
 6 
 
 5 
 
 118 
 
 101 
 
 
 
 
 
 1840.. 
 
 55 
 
 45 
 
 3 
 
 2 
 
 7 
 
 6 
 
 2 
 
 2 
 
 9 
 
 7 
 
 96 
 
 79 
 
 
 
 
 
 1841.. 
 
 84 
 
 67 
 
 5 
 
 4 
 
 8 
 
 6 
 
 • • • • 
 
 • • • • 
 
 8 
 
 6 
 
 98 
 
 78 
 
 
 
 
 
 1842.. 
 
 84 
 
 65 
 
 5 
 
 4 
 
 11 
 
 9 
 
 1 
 
 1 
 
 12 
 
 9 
 
 98 
 
 76 
 
 
 
 
 
 1843.. 
 
 58 
 
 44 
 
 2 
 
 2 
 
 5 
 
 4 
 
 4 
 
 3 
 
 9 
 
 7 
 
 120 
 
 90 
 
 
 
 
 
 1844.. 
 
 73 
 
 53 
 
 • • • • 
 
 • • • 
 
 6 
 
 4 
 
 1 
 
 1 
 
 7 
 
 5 
 
 93 
 
 68 
 
 
 
 
 
 1845.. 
 
 81 
 
 57 
 
 1 
 
 1 
 
 1 
 
 1 
 
 6 
 
 4 
 
 7 
 
 5 
 
 97 
 
 69 
 
 
 
 
 
 1846.. 
 
 73 
 
 50 
 
 • • • • 
 
 • • • 
 
 2 
 
 1 
 
 4 
 
 3 
 
 6 
 
 4 
 
 129 
 
 88 
 
 
 
 
 
 1847.. 
 
 81 
 
 54 
 
 • • • • 
 
 • • • 
 
 5 
 
 3 
 
 2 
 
 1 
 
 7 
 
 5 
 
 144 
 
 96 
 
 
 
 
 
 1848.. 
 
 106 
 
 69 
 
 • • • • 
 
 • • • 
 
 4 
 
 3 
 
 5 
 
 3 
 
 9 
 
 6 
 
 156 
 
 101 
 
 
 
 
 
 1849.. 
 
 97 
 
 61 
 
 1 
 
 1 
 
 8 
 
 5 
 
 1 
 
 1 
 
 9 
 
 6 
 
 171 
 
 107 
 
 
 
 
 
 1850.. 
 
 92 
 
 56 
 
 • • • • 
 
 • • • 
 
 3 
 
 2 
 
 6 
 
 4 
 
 9 
 
 5 
 
 140 
 
 85 
 
 2 
 
 1 
 
 • • • • 
 
 
 1851.. 
 
 99 
 
 59 
 
 1 
 
 1 
 
 8 
 
 5 
 
 
 
 8 
 
 5 
 
 156 
 
 93 
 
 3 
 
 2 
 
 
 
 1852.. 
 
 102 
 
 59 
 
 • • • • 
 
 
 11 
 
 6 
 
 
 
 11 
 
 6 
 
 174 
 
 100 
 
 4 
 
 2 
 
 
 
 1853.. 
 
 136 
 
 76 
 
 30 
 
 17 
 
 7 
 
 4 
 
 
 
 7 
 
 4 
 
 180 
 
 101 
 
 1 
 
 1 
 
 
 
 1854.. 
 
 116 
 
 63 
 
 184 
 
 100 
 
 7 
 
 4 
 
 
 
 7 
 
 4 
 
 184 
 
 100 
 
 7 
 
 4 
 
 
 
 1855.. 
 
 136 
 
 72 
 
 18 
 
 10 
 
 13 
 
 7 
 
 
 
 13 
 
 7 
 
 202 
 
 107 
 
 3 
 
 2 
 
 
 
 1856.. 
 
 127 
 
 66 
 
 8 
 
 4 
 
 11 
 
 6 
 
 
 
 11 
 
 6 
 
 188 
 
 97 
 
 2 
 
 1 
 
 
 
 1857.. 
 
 92 
 
 46 
 
 • • • • 
 
 • • • 
 
 15 
 
 8 
 
 
 
 15 
 
 8 
 
 185 
 
 93 
 
 4 
 
 2 
 
 
 
 1858.. 
 
 134 
 
 66 
 
 1 
 
 • • • 
 
 8 
 
 4 
 
 
 
 8 
 
 4 
 
 211 
 
 104 
 
 1 
 
 • • • • 
 
 
 
 1859.. 
 
 106 
 
 51 
 
 5 
 
 2 
 
 13 
 
 6 
 
 
 
 13 
 
 6 
 
 160 
 
 77 
 
 • • • • 
 
 • • • • 
 
 
 
 1860.. 
 
 112 
 
 52 
 
 2 
 
 1 
 
 11 
 
 5 
 
 
 
 11 
 
 5 
 
 215 
 
 100 
 
 4 
 
 2 
 
 
 
 1861.. 
 
 106 
 
 48 
 
 4 
 
 2 
 
 11 
 
 5 
 
 
 
 11 
 
 5 
 
 215 
 
 98 
 
 3 
 
 1 
 
 
 
 1862.. 
 
 98 
 
 43 
 
 6 
 
 3 
 
 21 
 
 9 
 
 
 
 21 
 
 9 
 
 190 
 
 84 
 
 2 
 
 1 
 
 
 
 1863.. 
 
 103 
 
 45 
 
 31 
 
 13 
 
 26 
 
 11 
 
 
 
 26 
 
 11 
 
 204 
 
 88 
 
 5 
 
 2 
 
 
 
 1864.. 
 
 91 
 
 38 
 
 33 
 
 14 
 
 21 
 
 9 
 
 
 
 21 
 
 9 
 
 202 
 
 85 
 
 1 
 
 • • • • 
 
 
 
 1865.. 
 
 100 
 
 41 
 
 22 
 
 9 
 
 23 
 
 • 
 
 9 
 
 
 
 23 
 
 9 
 
 167 
 
 69 
 
 2 
 
 1 
 
 
 
 * Including inanition, debility, asthenia, asphyxia neonatorum, atalectasis pulmonum, atrophy and 
 premature birth. After 1899 these affections have been classified under congenital malformations, con¬ 
 genital debility, inanition and other diseases peculiar to infancy. 
 
 (499) 
 
Table 12S .—Number of deaths and rate of death, per 100,000 living inhabitants, from convulsions, ma¬ 
 rasmus, rheumatism and gout, etc. —Continued. 
 
 D = death. R = rate. 
 
 Y ear. 
 
 Con¬ 
 
 vulsions. 
 
 Ma¬ 
 
 rasmus.* 
 
 Rheumatism and gout. 
 
 Senility. 
 
 Hernia and 
 intestinal 
 obstruction. 
 
 Appendicitis 
 and typhlitis. 
 
 Chronic 
 
 rheumatism and 
 gout. 
 
 Imflamma- 
 tory rheuma¬ 
 tism. 
 
 Total. 
 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 1866.. 
 
 202 
 
 81 
 
 46 
 
 19 
 
 20 
 
 8 
 
 
 
 20 
 
 8 
 
 219 
 
 88 
 
 2 
 
 1 
 
 
 
 1867.. 
 
 209 
 
 82 
 
 22 
 
 9 
 
 12 
 
 5 
 
 
 
 12 
 
 5 
 
 188 
 
 74 
 
 3 
 
 1 
 
 
 
 1868.. 
 
 301 
 
 116 
 
 26 
 
 10 
 
 28 
 
 11 
 
 
 
 28 
 
 11 
 
 199 
 
 76 
 
 1 
 
 • • • • 
 
 
 
 1869.. 
 
 289 
 
 108 
 
 67 
 
 25 
 
 49 
 
 18 
 
 
 
 49 
 
 18 
 
 229 
 
 86 
 
 1 
 
 • • • • 
 
 
 
 1870.. 
 
 298 
 
 109 
 
 74 
 
 27 
 
 34 
 
 12 
 
 
 
 34 
 
 12 
 
 327 
 
 120 
 
 2 
 
 I 
 
 
 
 1871.. 
 
 312 
 
 112 
 
 46 
 
 16 
 
 38 
 
 14 
 
 
 
 38 
 
 14 
 
 299 
 
 107 
 
 • • • • 
 
 • • • • 
 
 
 
 1872.. 
 
 305 
 
 107 
 
 33 
 
 12 
 
 53 
 
 19 
 
 
 
 53 
 
 19 
 
 314 
 
 no 
 
 10 
 
 4 
 
 
 
 1873.. 
 
 267 
 
 92 
 
 53 
 
 18 
 
 62 
 
 21 
 
 
 
 62 
 
 21 
 
 335 
 
 115 
 
 9 
 
 3 
 
 
 
 1874.. 
 
 328 
 
 110 
 
 63 
 
 21 
 
 48 
 
 16 
 
 
 
 48 
 
 16 
 
 289 
 
 97 
 
 8 
 
 3 
 
 
 
 1875.. 
 
 308 
 
 73 
 
 475 
 
 151 
 
 53 
 
 17 
 
 
 
 53 
 
 17 
 
 211 
 
 69 
 
 34 
 
 11 
 
 
 
 1876.. 
 
 361 
 
 116 
 
 533 
 
 171 
 
 50 
 
 16 
 
 
 
 50 
 
 16 
 
 240 
 
 77 
 
 26 
 
 8 
 
 
 
 1877.. 
 
 306 
 
 96 
 
 554 
 
 174 
 
 46 
 
 14 
 
 
 .... 
 
 46 
 
 14 
 
 211 
 
 66 
 
 23 
 
 7 
 
 
 
 1878.. 
 
 294 
 
 91 
 
 512 
 
 158 
 
 6 
 
 2 
 
 16 
 
 5 
 
 22 
 
 7 
 
 212 
 
 65 
 
 23 
 
 7 
 
 
 
 1879.. 
 
 323 
 
 97 
 
 538 
 
 162 
 
 3 
 
 1 
 
 28 
 
 8 
 
 31 
 
 9 
 
 255 
 
 77 
 
 25 
 
 8 
 
 
 
 1880.. 
 
 367 
 
 108 
 
 622 
 
 184 
 
 6 
 
 2 
 
 26 
 
 8 
 
 32 
 
 9 
 
 251 
 
 74 
 
 30 
 
 9 
 
 
 
 1881.. 
 
 419 
 
 121 
 
 620 
 
 179 
 
 7 
 
 2 
 
 32 
 
 9 
 
 39 
 
 11 
 
 251 
 
 73 
 
 19 
 
 6 
 
 1 
 
 
 1882.. 
 
 362 
 
 103 
 
 590 
 
 167 
 
 4 
 
 1 
 
 20 
 
 6 
 
 24 
 
 7 
 
 305 
 
 86 
 
 36 
 
 10 
 
 • • • • 
 
 
 1883.. 
 
 388 
 
 108 
 
 625 
 
 174 
 
 4 
 
 1 
 
 17 
 
 5 
 
 21 
 
 6 
 
 259 
 
 72 
 
 20 
 
 6 
 
 2 
 
 1 
 
 1884.. 
 
 342 
 
 93 
 
 680 
 
 185 
 
 10 
 
 3 
 
 19 
 
 5 
 
 29 
 
 8 
 
 282 
 
 77 
 
 37 
 
 10 
 
 3 
 
 1 
 
 1885.. 
 
 366 
 
 98 
 
 672 
 
 180 
 
 14 
 
 4 
 
 15 
 
 4 
 
 29 
 
 8 
 
 291 
 
 78 
 
 34 
 
 9 
 
 3 
 
 1 
 
 1886.. 
 
 319 
 
 84 
 
 755 
 
 198 
 
 15 
 
 4 
 
 32 
 
 8 
 
 47 
 
 12 
 
 248 
 
 65 
 
 28 
 
 7 
 
 • • • • 
 
 • • • • 
 
 1887.. 
 
 348 
 
 89 
 
 690 
 
 177 
 
 18 
 
 5 
 
 20 
 
 5 
 
 38 
 
 10 
 
 291 
 
 75 
 
 30 
 
 8 
 
 2 
 
 1 
 
 1888.. 
 
 304 
 
 72 
 
 724 
 
 173 
 
 24 
 
 6 
 
 23 
 
 5 
 
 47 
 
 11 
 
 318 
 
 76 
 
 43 
 
 10 
 
 4 
 
 1 
 
 1889.. 
 
 289 
 
 68 
 
 803 
 
 188 
 
 22 
 
 5 
 
 19 
 
 4 
 
 41 
 
 10 
 
 313 
 
 73 
 
 54 
 
 13 
 
 1 
 
 • • • • 
 
 1890.. 
 
 311 
 
 72 
 
 793 
 
 182 
 
 32 
 
 7 
 
 24 
 
 6 
 
 56 
 
 13 
 
 350 
 
 81 
 
 58 
 
 13 
 
 6 
 
 1 
 
 1891.. 
 
 352 
 
 80 
 
 837 
 
 189 
 
 25 
 
 6 
 
 11 
 
 2 
 
 36 
 
 8 
 
 431 
 
 98 
 
 55 
 
 12 
 
 6 
 
 1 
 
 1892.. 
 
 334 
 
 74 
 
 785 
 
 175 
 
 17 
 
 4 
 
 21 
 
 5 
 
 38 
 
 8 
 
 417 
 
 93 
 
 58 
 
 13 
 
 9 
 
 2 
 
 1893.. 
 
 259 
 
 57 
 
 840 
 
 184 
 
 28 
 
 6 
 
 24 
 
 5 
 
 52 
 
 11 
 
 329 
 
 72 
 
 53 
 
 12 
 
 13 
 
 3 
 
 1894.. 
 
 267 
 
 58 
 
 775 
 
 167 
 
 49 
 
 11 
 
 5 
 
 1 
 
 54 
 
 12 
 
 323 
 
 70 
 
 40 
 
 9 
 
 22 
 
 5 
 
 1895.. 
 
 293 
 
 62 
 
 828 
 
 176 
 
 37 
 
 8 
 
 4 
 
 1 
 
 41 
 
 9 
 
 317 
 
 67 
 
 41 
 
 9 
 
 18 
 
 4 
 
 1896.. 
 
 285 
 
 60 
 
 799 
 
 167 
 
 45 
 
 9 
 
 7 
 
 1 
 
 52 
 
 11 
 
 300 
 
 63 
 
 52 
 
 11 
 
 25 
 
 5 
 
 1897.. 
 
 252 
 
 52 
 
 815 
 
 168 
 
 40 
 
 8 
 
 4 
 
 1 
 
 44 
 
 9 
 
 255 
 
 52 
 
 76 
 
 16 
 
 34 
 
 7 
 
 1898.. 
 
 301 
 
 61 
 
 910 
 
 185 
 
 48 
 
 10 
 
 1 
 
 • • • • 
 
 49 
 
 10 
 
 362 
 
 73 
 
 54 
 
 11 
 
 34 
 
 7 
 
 1899.. 
 
 221 
 
 44 
 
 761 
 
 152 
 
 64 
 
 13 
 
 • • • • 
 
 • • • • 
 
 64 
 
 13 
 
 358 
 
 72 
 
 57 
 
 11 
 
 52 
 
 10 
 
 1900.. 
 
 277 
 
 55 
 
 919 
 
 181 
 
 41 
 
 8 
 
 • • • • 
 
 • • • • 
 
 41 
 
 8 
 
 339 
 
 67 
 
 75 
 
 15 
 
 63 
 
 12 
 
 1901.. 
 
 332 
 
 65 
 
 951 
 
 185 
 
 20 
 
 4 
 
 12 
 
 2 
 
 32 
 
 6 
 
 373 
 
 73 
 
 90 
 
 18 
 
 57 
 
 11 
 
 1902.. 
 
 168 
 
 32 
 
 1049 
 
 201 
 
 17 
 
 3 
 
 36 
 
 7 
 
 53 
 
 10 
 
 315 
 
 60 
 
 87 
 
 17 
 
 66 
 
 13 
 
 1903.. 
 
 136 
 
 26 
 
 896 
 
 170 
 
 10 
 
 2 
 
 48 
 
 9 
 
 58 
 
 11 
 
 258 
 
 49 
 
 81 
 
 15 
 
 60 
 
 11 
 
 1904.. 
 
 140 
 
 26 
 
 895 
 
 168 
 
 11 
 
 2 
 
 74 
 
 14 
 
 85 
 
 16 
 
 236 
 
 44 
 
 68 
 
 13 
 
 77 
 
 14 
 
 1905.. 
 
 146 
 
 27 
 
 903 
 
 167 
 
 9 
 
 2 
 
 53 
 
 10 
 
 62 
 
 11 
 
 231 
 
 43 
 
 64 
 
 12 
 
 52 
 
 10 
 
 1906.. 
 
 127 
 
 23 
 
 914 
 
 167 
 
 18 
 
 3 
 
 64 
 
 12 
 
 82 
 
 15 
 
 222 
 
 41 
 
 70 
 
 13 
 
 63 
 
 12 
 
 1907.. 
 
 156 
 
 28 
 
 928 
 
 168 
 
 13 
 
 2 
 
 69 
 
 12 
 
 82 
 
 15 
 
 276 
 
 50 
 
 87 
 
 16 
 
 55 
 
 10 
 
 1908.. 
 
 110 
 
 20 
 
 865 
 
 154 
 
 13 
 
 2 
 
 78 
 
 14 
 
 91 
 
 16 
 
 250 
 
 45 
 
 93 
 
 17 
 
 57 
 
 10 
 
 1909.. 
 
 97 
 
 17 
 
 818 
 
 144 
 
 20 
 
 4 
 
 59 
 
 10 
 
 79 
 
 14 
 
 216 
 
 38 
 
 105 
 
 19 
 
 61 
 
 11 
 
 1910.. 
 
 114 
 
 20 
 
 762 
 
 133 
 
 15 
 
 3 
 
 50 
 
 9 
 
 65 
 
 11 
 
 190 
 
 33 
 
 92 
 
 16 
 
 66 
 
 12 
 
 1911.. 
 
 63 
 
 11 
 
 691 
 
 119 
 
 14 
 
 2 
 
 50 
 
 9 
 
 64 
 
 11 
 
 166 
 
 29 
 
 83 
 
 14 
 
 78 
 
 13 
 
 1912.. 
 
 67 
 
 11 
 
 909 
 
 156 
 
 16 
 
 3 
 
 35 
 
 6 
 
 5l\ 
 
 9 
 
 213 
 
 36 
 
 98 
 
 17 
 
 59 
 
 10 
 
 1913.. 
 
 61 
 
 10 
 
 812 
 
 138 
 
 37 
 
 6 
 
 35 
 
 6 
 
 72 j 
 
 12 
 
 166 
 
 28 
 
 118 
 
 20 
 
 63 
 
 11 
 
 1914.. 
 
 48 
 
 8 
 
 813 
 
 136 
 
 39 
 
 7 
 
 36 
 
 6 
 
 75 
 
 13 
 
 170 
 
 29 
 
 111 
 
 19 
 
 80 
 
 13 
 
 1915.. 
 
 31 
 
 5 
 
 696 
 
 116 
 
 17 
 
 3 
 
 40 
 
 7 
 
 57 
 
 9 
 
 96 
 
 16 
 
 87 
 
 14 
 
 69 
 
 11 
 
 1916.. 
 
 30 
 
 5 
 
 720 
 
 119 
 
 10 
 
 2 
 
 24 
 
 4 
 
 34 
 
 6 
 
 85 
 
 14 
 
 93 
 
 15 
 
 76 
 
 13 
 
 1917.. 
 
 17 
 
 3 
 
 726 
 
 119 
 
 14 
 
 2 
 
 52 
 
 8 
 
 66 
 
 11 
 
 86 
 
 14 
 
 no 
 
 18 
 
 96 
 
 16 
 
 1918.. 
 
 17 
 
 3 
 
 837 
 
 136 
 
 11 
 
 2 
 
 44 
 
 7 
 
 55 
 
 9 
 
 105 
 
 17 
 
 111 
 
 18 
 
 79 
 
 13 
 
 1919.. 
 
 18 
 
 3 
 
 756 
 
 105 
 
 14 
 
 2 
 
 36 
 
 5 
 
 50 
 
 7 
 
 63 
 
 9 
 
 109 
 
 15 
 
 91 
 
 13 
 
 1920.. 
 
 16 
 
 2 
 
 856 
 
 117 
 
 13 
 
 2 
 
 40 
 
 5 
 
 ) 
 
 53i 
 
 1 
 
 7 
 
 58 
 
 8 
 
 ■ 
 
 102 
 
 14 
 
 96 
 
 13 
 
 * Including inanition, debility, asthenia, asphyxia neonatorum, atalectasis pulmonum, atrophy and 
 premature birth. After 1899 these affections have been classified under congenital malformations, con¬ 
 genital debility, inanition and other diseases peculiar to infancy. 
 
 (500) 
 
MISCELLANEOUS CAUSES OF DEATH 
 
 501 
 
 a considerable number of deaths in certain years of the sixth, seventh, and 
 eighth decades of the nineteenth century. By 1875 it was comparatively 
 insignificant, and in 1899 it was absorbed in the new rubric, congenital 
 debility. Inanition entered the statistical nosology in 1873, and from 1875 
 to 1909 to it a large number of deaths was annually attributed. To asthenia, 
 atrophy, and asphyxia (the latter synonymous with atalectasis pulmonum) 
 deaths were credited from 1875 to 1898. Appearing first in 1875, premature 
 birth continued as an important assigned cause of death until 1898. All of 
 these rubrics gave place in 1899 to the three rubrics embracing causes of 
 death other than congenital malformations peculiar to early infancy. Since 
 with few exceptions deaths from congenital malformations occur shortly after 
 birth, and since, except under hydrocephalus, which in the earlier years held 
 an entirely different significance (see meningitis), this cause can be traced 
 but rarely, the conclusion is forced that before 1899 they were included under 
 one of the headings of the group under discussion. The great and steady 
 increase in the importance of the rubric congenital malformations since its 
 introduction in 1899 can only be explained by change in custom of classifica¬ 
 tion of deaths. For these reasons it has seemed necessary to include this 
 rubric also. Indeed, it is not unlikely that most of the deaths in early infancy 
 are in a broad sense due to congenital defects which render extra-uterine 
 existence under adverse conditions impracticable. 
 
 DEATHS OF INFANTS FROM CAUSES UNKNOWN. 
 
 From table 132 it will be observed that this rubric appeared first in 1820, 
 when distinction was made between deaths in infants and in adults from 
 unknown causes. From the much higher rates which from 1820 were ascribed 
 consistently under this heading to infants, it is reasonable to suppose that 
 the same held good before this date. High rates characterized this rubric until 
 1875, after which, with the growing importance of the other rubrics under 
 consideration, it gradually declined to insignificance, to disappear completely 
 after 1893. After all, when obvious congenital defects and infections (syphilis, 
 umbilical-cord infection, cholera infantum, and the eruptive and respiratory 
 diseases) are excluded, most deaths of infants are really due to causes yet 
 unknown, and former generations were not unwise in declining to accept names 
 as true explanations. The rates for these three rubrics, convulsions, marasmus, 
 and causes unknown, separately and combined as averaged for 5-year periods, 
 are given in table 129. It is obvious at a glance that no one or two of these 
 rubrics can be taken as the measure of the course of mortality for the causes 
 under consideration. Taking the total for all three rubrics, it is found that 
 from 1821 to 1920 the curve is a fairly consistent one. Starting at 371 for 
 the period 1821-1825, the rate was well over 500 during the next three quin¬ 
 quennia. From 1841 to 1890, the rate, except for the period 1871-1875, did 
 not depart far from 400. There was a slight fall from 380 for 1886-1890 
 to 357 for 1896-1900. No material change was brought about in the rate by 
 the falling out after 1875 of causes unknown as an important rubric. The 
 rubric marasmus immediately rose correspondingly. 
 
 If the assumptions and inferences upon which these rubrics have been set 
 up are in the main valid, the fluctuations in the total rate between 1820 and 
 1900 are probably no greater than would be expected from errors of classifica¬ 
 tion of deaths and variations, due to changes in the birth-rate, in the propor- 
 
502 PUBLIC HEALTH ADMINISTRATION", ETC., IN' BALTIMORE 
 
 tional distribution in the population of individuals of the restricted age-group 
 under consideration. Since 1900, however, a very considerable but gradual 
 decline has taken place. From 357 for the period 1896-1900, the rate fell to 
 122 for that ending in 1920. In the 20 years since 1900 the rubrics of classifica¬ 
 tion are clear-cut and no ambiguity as to their meaning and content befogs 
 the question. All the evidence at hand indicates that the birth-rate can have 
 varied but little during this period. Since deaths from the causes now under 
 discussion occur almost exclusively in the first year of life and include a very 
 large proportion of deaths from all causes (40 to 50 per cent) in this age- 
 period, there should be a close correspondence between the course of the rates 
 just discussed and the percentage of deaths under 1 year of age to the total 
 deaths at all ages. As a matter of fact (table 138), the latter varied within 
 
 Table 129. —Average rate of death, per 100,000 living inhabitants, by 6-year periods, 
 from certain diseases of early infancy, from 1812 to 1920, inclusive. 
 
 Periods. 
 
 Convulsions. 
 
 Marasmus.* 
 
 Total. 
 
 Causes unknown 
 (infantile). 
 
 Total. 
 
 
 Periods. 
 
 Convulsions. 
 
 Marasmus.* 
 
 Total. 
 
 Causes unknown 
 
 (infantile). 
 
 Total. 
 
 1812-15 
 
 
 163 
 
 • • • • 
 
 163 
 
 • • • • 
 
 163 
 
 
 1866-70 
 
 
 99 
 
 22 
 
 121 
 
 337 
 
 458 
 
 1816-20 
 
 • • • • 
 
 183 
 
 • • • • 
 
 183 
 
 • • • • 
 
 183 
 
 
 1871-75 
 
 • • • • 
 
 99 
 
 57 
 
 156 
 
 213 
 
 369 
 
 1821-25 
 
 • • • • 
 
 99 
 
 34 
 
 133 
 
 238 
 
 371 
 
 
 1876-80 
 
 • • • • 
 
 102 
 
 275 
 
 377 
 
 15 
 
 392 
 
 1826-30 
 
 • • • • 
 
 81 
 
 57 
 
 139 
 
 400 
 
 539 
 
 
 1881-85 
 
 • • • • 
 
 105 
 
 287 
 
 392 
 
 10 
 
 402 
 
 1831-35 
 
 • • • • 
 
 96 
 
 34 
 
 130 
 
 443 
 
 573 
 
 
 1886-90 
 
 • • • • 
 
 77 
 
 299 
 
 376 
 
 4 
 
 380 
 
 1836-40 
 
 • • • • 
 
 70 
 
 20 
 
 89 
 
 444 
 
 533 
 
 
 1891-95 
 
 • • • • 
 
 66 
 
 291 
 
 357 
 
 f4 
 
 361 
 
 1841-45 
 
 • • • • 
 
 57 
 
 2 
 
 59 
 
 370 
 
 429 
 
 
 1896-1900 .. 
 
 54 
 
 303 
 
 357 
 
 • • • • 
 
 357 
 
 1846-50 
 
 • • • • 
 
 58 
 
 • • • • 
 
 58 
 
 363 
 
 421 
 
 
 1901-05 
 
 • • • • 
 
 35 
 
 178 
 
 213 
 
 • • • • 
 
 213 
 
 1851-55 
 
 • • • • 
 
 66 
 
 26 
 
 92 
 
 322 
 
 414 
 
 
 1906-10 
 
 • • • • 
 
 22 
 
 153 
 
 175 
 
 • • • • 
 
 175 
 
 1856-60 
 
 • • • • 
 
 56 
 
 2 
 
 58 
 
 336 
 
 394 
 
 
 1911-15 
 
 • • • • 
 
 9 
 
 133 
 
 142 
 
 • • • • 
 
 142 
 
 1861-65 
 
 .... 
 
 43 
 
 9 
 
 52 
 
 327 
 
 379 
 
 
 1916-20 
 
 .... 
 
 3 
 
 119 
 
 122 
 
 .... 
 
 122 
 
 * Including inanition, debility, asthenia, asphyxia neonatorum, atalectasis pulmonum, 
 atrophy, and premature birth. After- 1899, these affections have been classified under 
 congenital malformations, congenital debility, inanition, and other diseases. 
 
 f Averaged for three years only. 
 
 comparatively narrow limits between 1816-1820 and 1886-1890, and for the 
 latter period stood at 29 per cent. From this time the decline was steadily to 
 16 per cent for 1916-1920, a decrease of 45 per cent. In the same space of 
 time, i. e., since 1890, the decline in the rate for causes peculiar to infancy was 
 about 63 per cent. When due allowance is made for crudeness of the basis 
 of comparison the correlation is strikingly high. An apter comparison is 
 that between the averaged crude rates and the rates specific for the first year 
 of life for this group of affections determined for the census years. These are 
 found to be for 1850, 11,049; for 1860, 12,726; for 1880, 12,041; for 1890, 
 11,686; for 1900, 11,029; for 1910, 8,556; and for 1920, 5,871. Between 
 1850 and 1900 the decline in the average crude rate was 15 per cent and the 
 change in the specific rate was negligible, while, since 1900, the former fell 
 by 65 and the latter by 46 per cent. All things considered, the correspondence 
 is close. 
 
 Whatever doubt may be thrown on the accuracy of the picture of the course 
 of mortality from this group of causes during the previous 80 years, when the 
 
MISCELLANEOUS CAUSES OF DEATH 
 
 503 
 
 rates for the initial and closing periods were approximately the same, there 
 can be no question that during the last 20 years the rates must reflect actual 
 experience with a reasonable degree of accuracy. While the assumption that 
 fatal syphilis was more common in the earlier years may not be successfully 
 combated, and that in the period of the prevalence of certain diseases in severe 
 and often epidemic states premature births were probably more common must 
 be acknowledged, more adequate explanations than these are needed to account 
 for the recent sensible drop in mortality from a group of affections in the 
 causation of which infectious processes other than syphilis play a subordinate 
 role. 
 
 On the other hand, in the period of falling rates there have been in play, and 
 with a correspondingly increasing intensity of activity, a set of influences 
 rightly designed to accomplish this very purpose. In so far as deaths from 
 causes peculiar to infancy are preventable, the result is reached by improvement 
 in the care of infants before and after birth. It was in this 20-year period 
 
 Table 130 .—Number of deaths and rate of death, per 100,000 live-births, from certain diseases 
 of early infancy and number of live-briths, according to color and sex, for 1920. 
 
 D = death. R = rate. 
 
 • 
 
 Total. 
 
 White. 
 
 Colored. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 Number of live-births 
 
 18787 
 
 15934 
 
 8159 
 
 7775 
 
 2853 
 
 1436 
 
 1417 
 
 Convulsions . 
 
 16 
 
 85 
 
 12 
 
 75 
 
 8 
 
 98 
 
 4 
 
 51 
 
 4 
 
 140 
 
 3 
 
 209 
 
 1 
 
 71 
 
 Congenital malforma- 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 tions . 
 
 190 
 
 1011 
 
 157 
 
 985 
 
 94 
 
 1152 
 
 63 
 
 810 
 
 33 
 
 1157 
 
 16 
 
 1114 
 
 17 
 
 1200 
 
 Congenital debility.. 
 
 510 
 
 2715 
 
 394 
 
 2473 
 
 220 
 
 2696 
 
 174 
 
 2238 
 
 116 
 
 4066 
 
 65 
 
 4526 
 
 51 
 
 3599 
 
 Other diseases pecu- 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 liar to early in- 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 fancy . 
 
 155 
 
 825 
 
 121 
 
 759 
 
 69 
 
 846 
 
 52 
 
 669 
 
 34 
 
 1192 
 
 21 
 
 1462 
 
 13 
 
 917 
 
 Lack of care. 
 
 1 
 
 5 
 
 1 
 
 6 
 
 
 
 1 
 
 13 
 
 
 
 
 
 
 
 • Total . 
 
 872 
 
 4642 
 
 685 
 
 4299 
 
 391 
 
 4792 
 
 294 
 
 3781 
 
 187 
 
 6555 
 
 105 
 
 7312 
 
 82 
 
 5787 
 
 that obstetric teaching and practice improved, obstetrical facilities were 
 extended, modern pediatrics with dispensaries and hospital care developed, 
 and instruction of mothers through the Visiting Nurse and the Babies Milk 
 Fund Associations has been carried out on an. ever-increasing scale. Owing 
 to the exposure of the deadly foundling asylums by a special committee, since 
 1914 the doors of these institutions have been closed to infants under 6 
 months of age. A class of babies heretofore condemned to almost certain 
 death have thus been retained in the care of their mothers during the most 
 risky period of existence. 
 
 In the same period the racial complex of the population has undergone 
 changes favorable to decrease in infant mortality. The proportion of negroes 
 to whites has decreased, and the ratio of race stocks—Polish Jews, Poles, and 
 Italians—among whom infant suckling is the rule—has increased. On the 
 basis of the live-births reported, rates specific for sex and color for the rubrics 
 covering deaths really peculiar to infants in 1920 are given in table 130. 
 
504 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 From this table it is clear that not only for the total of all the rubrics, but for 
 each separate rubric where the figures are large enough to be significant, the 
 rates were much higher among negroes than among whites and among males 
 than among females. Of the total number of those deaths, the percentage 
 for each rubric that occurred within the first year of life was as follows: 
 convulsions, 81; congenital malformations, 95; congenital debility, 98; other 
 diseases of infants and lack of care, each, 100. There occurred during the 
 first month of life of the total number dying under 1 year of age, of con¬ 
 vulsions, 31 per cent; of congenital malformations, 69 per cent; of congenital 
 debility, 85 per cent; of other diseases of infancy, 97.4 per cent; and of lack 
 of care, 100 per cent. There can be little doubt, therefore, that this group of 
 causes of death corresponds to those that have been discussed above. 
 
 ARTHRITIS. 
 
 Deaths have been classified in the mortality tables as due to gout or rheuma¬ 
 tism, either chronic or unqualified, with a single exception, in each year since 
 1812. To acute rheumatism were assigned a few deaths in occasional years 
 
 Table 131 .—Average rate of death, per 100,000 living inhabitants, by 5-year periods, 
 from rheumatism and gout, senility, hernia and intestinal obstruction, and appen¬ 
 dicitis, from 1812 to 1920, inclusive. 
 
 Periods. 
 
 Rheumatism and 
 gout. 
 
 Hernia and intestinal 
 obstruction. 
 
 Appendicitis and 
 typhlitis- 
 
 
 Periods. 
 
 Rheumatism and 
 gout. 
 
 Hernia and Intestinal 
 obstruction. 
 
 Appendicitis and 
 
 typhlitis. 
 
 Chronic rheuma¬ 
 tism and gout. 
 
 Inflammatory 
 
 rheumatism. 
 
 Total. 
 
 Chronic rheuma¬ 
 tism and gout. 
 
 Inflammatory 
 
 rheumatism. 
 
 Total. 
 
 1812-15 
 
 
 5 
 
 
 5 
 
 
 
 
 1866-70 
 
 • • • • 
 
 11 
 
 • • • • 
 
 11 
 
 1 
 
 • • • • 
 
 1816-20 
 
 • • • • 
 
 7 
 
 1 
 
 8 
 
 
 
 
 1871-75 
 
 • • • • 
 
 17 
 
 • • • • 
 
 17 
 
 4 
 
 • • • • 
 
 1821-25 
 
 • • • • 
 
 10 
 
 • • • • 
 
 10 
 
 
 
 
 1876-80 
 
 • • • • 
 
 7 
 
 4 
 
 11 
 
 8 
 
 • • • • 
 
 1826-30 
 
 • • • • 
 
 5 
 
 1 
 
 6 
 
 
 
 
 1881-85 
 
 • • • • 
 
 2 
 
 6 
 
 8 
 
 8 
 
 • • • • 
 
 1831-35 
 
 • • • • 
 
 5 
 
 1 
 
 6 
 
 
 
 
 1886-90 
 
 • • • • 
 
 5 
 
 6 
 
 11 
 
 10 
 
 1 
 
 1836-40 
 
 • • • • 
 
 3 
 
 2 
 
 5 
 
 
 
 
 1891-95 
 
 • • • • 
 
 7 
 
 3 
 
 10 
 
 11 
 
 3 
 
 1841-45 
 
 • • • • 
 
 5 
 
 2 
 
 7 
 
 
 
 
 1896-1900 .. 
 
 9 
 
 1 
 
 10 
 
 13 
 
 8 
 
 1846-50 
 
 • • • • 
 
 3 
 
 2 
 
 5 
 
 • • • • 
 
 
 
 1901-05 
 
 • • • • 
 
 3 
 
 8 
 
 11 
 
 15 
 
 12 
 
 1851-55 
 
 • • • • 
 
 5 
 
 • • • • 
 
 5 
 
 2 
 
 
 
 1906-10 
 
 • • • • 
 
 3 
 
 11 
 
 14 
 
 16 
 
 11 
 
 1856-60 
 
 • • • • 
 
 6 
 
 • • • • 
 
 6 
 
 1 
 
 
 
 1911-15 
 
 • • • • 
 
 4 
 
 7 
 
 11 
 
 17 
 
 12 
 
 1861-65 
 
 • • • • 
 
 9 
 
 .... 
 
 9 
 
 1 
 
 
 
 1916-20 
 
 .... 
 
 2 
 
 6 
 
 8 
 
 16 
 
 13 
 
 between 1819 and 1850. This rubric disappeared completely from 1851 to 
 1878. It reappeared, however, in 1878, and with the exception of two years 
 it has been credited with deaths in each succeeding year. The annual data 
 for these two rubrics are presented in table 128. These do not include deaths 
 ascribed to disease of the hip-joint, the knee, and the spinal vertebras, which 
 have elsewhere been classified under tuberculosis. They do include, however, 
 deaths from all other anatomical and etiological varieties of arthritis. It has not 
 been possible to distinguish between true gout and other forms of arthritis, 
 and it is evident from the table that not until 1901 and after is any significant 
 distinction between acute and chronic arthritis warranted. 
 
 Taking the recorded figures at their face value, and using for convenience 
 rates averaged for 5-year periods (table 131), the mortality from presumably 
 
MISCELLANEOUS CAUSES OF DEATH 
 
 505 
 
 non-tuberculous arthritis as a whole may be studied with some profit. Up 
 until 1865 an average rate of from 5 to 7 obtained in each period, except in 
 1816-1820, 1821-1825, and 1861-1865, when it was 8, 10, and 9, respectively. 
 After 1865 the rate held remarkably steady at 10 or 11 in 7 out of 11 periods. 
 It fell to 8 in the periods 1881-1885 and 1916-1920, and rose to 17 and to 
 14, respectively, between 1871 and 1875 and 1906 and 1910. It will be noted 
 that the rate was the same in 1816-1820 and 1916-1920. In the 20 years 
 1901-1920, during which it may be followed separately with some degree of 
 certainty, the rate for acute rheumatism varied from 6 to 11, relatively wide 
 extremes. This suggests that the fluctuations noted in the total rate in earlier 
 years may have been due, in large measure at least, to exacerbations in the 
 mortality of acute arthritis of the type commonly known as acute inflamma¬ 
 tory rheumatism. 
 
 HERNIA AND INTESTINAL OBSTRUCTION. 
 
 Deaths under this rubric can not be traced in the mortality tables before 
 1850, and for many subsequent years most of the small mortality from these 
 causes was classified under hernia. It was not until 1875 that the annual rates 
 (table 128) became significant. Beginning in this year with a rate of 11, and 
 fluctuating during the following 13 years between 6 and 10, the annual rate 
 reached 13 in 1889. In only two years since this date did the rate again fall 
 below 11. After 1899 the course of the annual rates follows definite short 
 waves of irregular length, with rates in the peak year of 18 in 1901, 19 in 
 1909, 20 in 1913, and 18 in 1917 and 1918. 
 
 When averaged for 5-year periods (table 131), the rate was 8 from 1876 to 
 1885, 10 from 1886 to 1890, 11 from 1891 to 1895, and 13 from 1896 to 
 1900. During the next 20 years, a period of more discriminating classifica¬ 
 tion of deaths and of more frequent surgical intervention, with perfected 
 technique in this group of affections for which mechanical measures offer 
 almost the sole hope of prevention and cure, the rate as averaged for 5-year 
 periods has remained almost stationary—from 15 to 17. At first sight it 
 would appear that rates of this level represent the natural inevitable mor¬ 
 tality from this group of causes. Analysis of the facts and probabilities 
 of the case shows that this view is untenable. In the first place, while improve¬ 
 ments in diagnosis and classification have undoubtedly relegated to other 
 rubrics many deaths which before 1899 would have been classified under this 
 heading, it is certain that many deaths following acute intestinal obstruction 
 within a few days after abdominal operations have been assigned to this rubric, 
 instead of to those covering the affections for which operation was under¬ 
 taken. Personal experience has demonstrated that the utmost care is required 
 to avoid this trap, which, owing to ignorance or intention on the part of 
 surgeons, is so frequently set for statistical clerks. In the second place, as a 
 result of the greatly increased frequency and impunity with which abdominal 
 operations have been undertaken in this period, and the relatively small imme¬ 
 diate fatality, there has accumulated in the population a not inconsiderable 
 number of persons with intestinal adhesions or even progressive chronic peri¬ 
 tonitis, likely to cause obstruction of the intestines. Therefore it may well 
 be that the very measures beneficent in so many respects, which in many 
 instances ward off death from some affections belonging under this group, 
 have in one way or another served to stabilize its officially recorded death-rate 
 at a relatively high level. 
 
PART VIII.—GENERAL CONCLUSIONS. 
 
 Chapter XIX. —Deaths from All Causes. 
 
 (Tables 132 to 139, graphs 35 to 41.) 
 
 From table 132 and graph 35 it will be observed that for the population as a 
 whole the course of mortality has varied widely during the 109 years under 
 review. Throughout most of this period, however, with few exceptions, as, 
 for instance, about 1819, 1832, 1872, and 1918—all years of unusual epi¬ 
 demics marked by extraordinary mortality—any striking fluctuations in the 
 annual rates extended over considerable periods of years. Until 1895, the 
 curve of the annual rates ran a wave-like course. Between 1812 and 1817, the 
 rate varied between 2,892 and 2,598. Bising to 3,226 in 1818 and to 3,933, 
 the highest ever attained, in 1819, the rate fell to 2,639 in 1820. Ascending 
 to 3,499 in 1822, the rate declined to 2,006 in 1824 and to 1,824 in 1827. 
 During the next 4 years the rate ascended gradually to 2,459 in 1831. Under 
 the influence of severe epidemics of cholera and influenza and a moderate 
 visitation of small-pox in 1832, the rate reached 3,720. By 1835 the rate 
 had fallen to 1,852, and in 9 of the succeeding years it was under 2,100; 
 in 1840 it was as low as 1,690. From 1847 the rate gradually ascended until 
 1854, when it reached 2,916. From this level there was a gradual though 
 somewhat irregular decline to 1,935 in 1865. A second long wave beginning 
 in 1866 reached its peak with a rate of 3,103 in 1872, and by 1878 had fallen 
 to 2,073. From 1879 to 1883 the rate gradually ascended to 2,607, and from 
 this level there was a continuous decline to 2,038 in 1889. From this time 
 until 1907, except for slight rises in 1890-1892 and in 1895, the rate fluctu¬ 
 ated between 2,100 and 1,923. During the following 10 years the rate was 
 always below 1,900, and in one year, 1915, below 1,700. It rose to 2,596 in 
 1918, to fall to the lowest recorded levels, 1,585 and 1,548 in 1919 and 1920, 
 respectively. It will be observed that, while in several years in the third, 
 fourth, fifth, and seventh decades the rate fell below 2,000, it was not until 
 the twentieth century that rates so low were common, nor until after 1908 
 were they of constant (except in 1918) occurrence. It was only after 1895 
 that these marked waves of increased mortality ceased to appear. 
 
 In considering the difference in the course of mortality in the white and 
 negro races, and in comparing the curves for these with that for the total 
 population, it must be borne in mind that until 1857 the rates for whites and 
 negroes separately are based on figures which include still-births. This is due 
 to the fact that until this date in the tables of mortality the white and negro 
 still-births were not tabulated separately. In consequence these rates are for 
 this period somewhat higher than would be the true rates calculated on the 
 usual basis, and the difference between the white rate and the total rate is less 
 marked and between the total rate and the negro rate is more pronounced 
 than would be the case but for this fault in the original data. As throughout 
 33 507 
 
Table 132. — Deaths from all causes, exclusive of still-births* per 100,000 living inhabitants, from 1812 to 1920, inclusive. 
 
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 Number of deaths and the rates of death for white and colored include still-births from 1818 to 1856, inclusive. 
 
Table 132. —Deaths from all causes, exclusive of still-births. —Continued. 
 
 D = death. R = rate. 
 
 510 
 
 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
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GENERAL CONCLUSIONS 
 
 511 
 
 the whole period the whites have constituted a so overwhelmingly large pro¬ 
 portion of the population, their rate has been the determining factor in the 
 rate for the whole population. It is not surprising, therefore, that before 1857 
 the white rate as calculated approaches or even surpasses the level of the total 
 rate. As the chief interest in the comparison lies in the differences between 
 the wdiite and the negro rates, the inclusion of still-births in the earlier period 
 is of relatively minor importance. Comparing the rates for these two elements 
 in the population from 1817 to 1920, inclusive, it is notable that with the 
 exception of a few years (1821, 1853, 1854, 1862, 1863), the negro rate was 
 higher than the white rate. Except in 1821 and between 1851 and 1868, the 
 difference in favor of the whites is striking. The near approach of the two 
 
 Graph 35 (from table 132). Animal crude mortality-rates from all causes 
 in the whole population, in whites, and in negroes, from 1812 to 1920, in¬ 
 clusive. 
 
 rates in the sixth and seventh decades of the nineteenth century occurred in 
 a period of very marked decline in the proportion of negroes to whites in the 
 population. To a certain degree, at least, the decline in the rate for negroes 
 in this period was also associated with the higher proportion of cases of small¬ 
 pox and typhus fever in this race hospitalized without the city limits. With 
 the exceptions above noted, there is a very definite correspondence between the 
 course of the curves for the two rates, which rise and fall together, and but 
 for the difference in their levels, the three curves follow much the same courses. 
 
 The course of the rate for whites followed so closely that of the rate for 
 the whole population until 1875 that it is unnecessary to trace it separately. 
 From 1885, with the exception of 1890 to 1892, inclusive, and 1918, the white 
 rate never exceeded 2,000, and, after 1905, in only one year (1918) did it rise 
 
512 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 above 1,800. It dropped below 1,500 for the first time in 1915, and in 1920 it 
 fell to 1,404. In 1918, the year of the great influenza epidemic, this rate 
 attained 2,374, a level relatively low when compared with certain earlier years. 
 Particularly high rates in the earlier period were 3,043 in 1818, 4,034 in 1819 
 (yellow fever); 3,408, 3,552, and 2,832 in 1821, 1822, and 1823; 3,032 in 1832 ; 
 3,015, 2,909, 3,130, 2,856, and 2,904 in 1852, 1853, 1854, 1855, and 1856, 
 respectively, and 2,970 in 1872. These very high rates were associated with 
 years of severe visitations of yellow fever, cholera, typhus fever, or small¬ 
 pox. The 6-year period between 1839 and 1844, when the rate never exceeded 
 2,000, was peculiarly healthy. 
 
 Between 1817 and 1852 the rate in negroes fell below 3,000 in only 8 
 years. The lowest rate recorded in this period was 2,449 in 1840. Extra¬ 
 ordinarily high rates were 4,573, 4,409, 4,180, and 4,621 in 1818, 1819, 1822, 
 and 1823, respectively; 6,573 in 1832, 3,829 in 1872, 3,775 in 1877, 3,945, 
 3,772, and 4,078 in 1881 to 1883, and 3,757 in 1918. Rates uniformly 
 below 3,000 occurred between 1857 and 1869, and in this period rates under 
 2,400 were recorded in 5 years. Between 1870 and 1907, the rates fell below 
 3,000 in only two years. After the latter date the rate rose above 3,000 in 
 only two years (1917 and 1918). From 1885 to 1907 the rates ran on a fairly 
 even level and not far from 3,000. The decline to 2,440 and 2,370 for 1919 
 and 1920, respectively, while striking, did not bring the rate below levels 
 previously recorded. 
 
 Turning now to rates averaged for 5-year periods (table 133, graph 36), 
 the course of mortality from all causes can be followed with greater clearness. 
 For the whole population the rates rose from 2,758 for the period 1812-1815 
 to 3,019 for the quinquennium ending in 1820. For the next 5 years the rate 
 fell to the level of the first period, and for 1826-1830 it declined to 2,149. 
 Between 1831 and 1835 the rate rebounded to '2,609, only to fall again to 
 2,034 for 1836-1840 and to the extremely low level of 1,892 for 1841-1845, 
 a level not to be bettered until 1911-1915. The wave extending over the 20 
 years between 1846 and 1865 reached its peak with a rate of 2,728 for the 
 5-year period 1851-1855. Descending to 2,241 for the quinquennium 1861- 
 1865, the rate gradually ascended again, and for the 5 years ending in 1875 
 was 2,625. Falling slightly between 1876 and 1880 and rising somewhat for 
 the next 5-year period, the rate declined to 2,170 for the 5 years ending in 
 1890. After remaining practically stationary for the succeeding quinquennium, 
 from 1896 the averaged rate fell steadily to 1,749 during the quinquennium 
 1911-1915. For 1916-1920 the rate was 1,870. 
 
 The curve of the white rate ran nearly parallel with that for the total rate 
 until 1875. After this date it dropped substantially and almost unbrokenly 
 until 1915. For the period 1841-1845, the rate for this category was only 
 1,870. The highest levels reached were 3,209 in 1816-1820, 2,766 in 1821- 
 1826, and 2,899 in 1851-1855. The rate had declined to 1,988 by 1886-1890. 
 The low point was reached in 1911-1915 with a rate of 1,568. 
 
 The rate for negroes, like the total rate and the white rate, fell continuously 
 from 1816 to 1830, and also like these but for the ascent between 1831-1840 
 it would have continued at a comparatively low level until 1845. The peak 
 periods 1816-1820 and 1831-1835 were characterized by the excessively high 
 rates of 4,220 and 4,124, respectively. From a level of 2,861 for the quin- 
 
GENERAL CONCLUSIONS 
 
 513 
 
 Table 133 j —Average rate of death, per 100,000 living inhabitants, by 5-year periods, 
 from all causes excluding still-births, total causes unknown, and still-births, from 
 1812 to 1920, inclusive. 
 
 Periods. 
 
 Deaths from all 
 causes, exclud¬ 
 ing still-births. 
 
 Total causes 
 unknown. 
 
 Still-births. 
 
 
 Periods. 
 
 Deaths from all 
 causes, exclud¬ 
 ing still-births. 
 
 Total causes 
 
 unknown. 
 
 Still-births. 
 
 i 
 
 Total. 
 
 White.* 
 
 Colored.* 
 
 Total. 
 
 White.* 
 
 Colored.* 
 
 1812-15_ 
 
 2758 
 
 • • • • 
 
 • • • • 
 
 145 
 
 219 
 
 
 1866-70 _ 
 
 2363 
 
 2290 
 
 2756 
 
 399 
 
 163 
 
 1816-20_ 
 
 3019 
 
 3209 
 
 4220 
 
 143 
 
 186 
 
 
 1871-75 _ 
 
 2625 
 
 2482 
 
 3401 
 
 248 
 
 159 
 
 1821-25 .... 
 
 2756 
 
 2766 
 
 3472 
 
 278 
 
 162 
 
 
 1876-80 _ 
 
 2328 
 
 2116 
 
 3491 
 
 19 
 
 187 
 
 1826-30 _ 
 
 2149 
 
 2073 
 
 3082 
 
 457 
 
 127 
 
 
 1881-85 _ 
 
 2425 
 
 2199 
 
 3668 
 
 13 
 
 190 
 
 1831-35 _ 
 
 2609 
 
 2430 
 
 4124 
 
 473 
 
 143 
 
 
 1886-90 _ 
 
 2170 
 
 1988 
 
 3182 
 
 5 
 
 180 
 
 1836-40 _ 
 
 2034 
 
 1986 
 
 3182 
 
 466 
 
 169 
 
 
 1891-95 _ 
 
 2191 
 
 2000 
 
 3253 
 
 5 
 
 166 
 
 1841-45 .... 
 
 1892 
 
 1870 
 
 2861 
 
 410 
 
 149 
 
 
 1896-1900 .. 
 
 2048 
 
 1846 
 
 3168 
 
 7 
 
 143 
 
 1846-50 _ 
 
 2401 
 
 2484 
 
 3400 
 
 437 
 
 236 
 
 
 1901-05 _ 
 
 1987 
 
 1762 
 
 3222 
 
 21 
 
 136 
 
 1851-55 _ 
 
 2728 
 
 2899 
 
 3088 
 
 379 
 
 201 
 
 
 1906-10 .... 
 
 1912 
 
 1703 
 
 3006 
 
 54 
 
 145 
 
 1856-60 _ 
 
 2488 
 
 2507 
 
 2675 
 
 409 
 
 199 
 
 
 1911-15_ 
 
 1749 
 
 1568 
 
 2713 
 
 13 
 
 151 
 
 1861-65 _ 
 
 2241 
 
 2226 
 
 2322 
 
 390 
 
 138 
 
 
 1916-20_ 
 
 1870 
 
 1682 
 
 2893 
 
 1 
 
 196 
 
 * These averages for white and colored include still-births until 1857. 
 
 Graph 36 (from table 133). Crude mortality-rates from all causes in the 
 whole population, in whites, and in negroes, averaged by 5-year periods, 
 from 1812 to 1920, inclusive. 
 
514 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 quennium 1841-1846, the rate for negroes rose comparatively slightly during 
 the succeeding 5 years and, in contrast to the rate for whites, instead of con¬ 
 tinuing to rise between 1851-1855 and attaining a higher peak, it entered 
 upon a long decline covering the 15 years between 1851 and 1865, and for the 
 period 1861-1865 stood at 2,322. These 15 years were a period of stagnation 
 in negro immigration, during which the negro population declined actually 
 and relatively. Again, after 1865 the course of the rate for negroes followed 
 a course rather different from that pursued by the rate for whites. While 
 between 1866 and 1875 the rate for whites showed only a slight increase, that 
 for negroes rose to 2,756 for 1866-1870, 3,401 for 1871-1875, 3,491 for 
 
 Table 134.— Number of deaths and rate of death, per 100,000 living inhabitants, from all causes, by 
 
 color and sex, from 1878 to 1920, inclusive. 
 
 D = death. R = rate. 
 
 Year. 
 
 White. 
 
 Colored. 
 
 Year. 
 
 White. 
 
 Colored. 
 
 Male. 
 
 Fem. 
 
 Male. 
 
 1 
 
 Fem. 
 
 Male. 
 
 Fem. 
 
 Male. 
 
 Fem. 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 1878 
 
 2556 
 
 1924 
 
 2603 
 
 1834 
 
 716 
 
 3376 
 
 858 
 
 2975 
 
 1900 
 
 4179 
 
 2012 
 
 3914 
 
 1767 
 
 1251 
 
 3606 
 
 1356 
 
 3149 
 
 1879 
 
 2970 
 
 2190 
 
 2913 
 
 2010 
 
 851 
 
 3921 
 
 884 
 
 3011 
 
 1901 
 
 4095 
 
 1943 
 
 3761 
 
 1678 
 
 1336 
 
 3788 
 
 1287 
 
 2947 
 
 1880 
 
 3180 
 
 2297 
 
 2990 
 
 2020 
 
 888 
 
 3998 
 
 985 
 
 3295 
 
 1902 
 
 4072 
 
 1905 
 
 3661 
 
 1614 
 
 1274 
 
 3553 
 
 1246 
 
 2814 
 
 1881 
 
 3402 
 
 2407 
 
 3317 
 
 2195 
 
 1008 
 
 4436 
 
 1089 
 
 3579 
 
 1903 
 
 4027 
 
 1858 
 
 3632 
 
 1583 
 
 1214 
 
 3331 
 
 1268 
 
 2825 
 
 1882 
 
 3607 
 
 2501 
 
 3273 
 
 2122 
 
 1007 
 
 4332 
 
 1038 
 
 3352 
 
 1904 
 
 4271 
 
 1944 
 
 3825 
 
 1649 
 
 1383 
 
 3734 
 
 1339 
 
 2944 
 
 1883 
 
 3659 
 
 2486 
 
 3466 
 
 2202 
 
 1078 
 
 4535 
 
 1177 
 
 3734 
 
 1905 
 
 4202 
 
 1888 
 
 3737 
 
 1594 
 
 1363 
 
 3622 
 
 1393 
 
 3022 
 
 1884 
 
 3340 
 
 2225 
 
 3058 
 
 1905 
 
 906 
 
 3727 
 
 989 
 
 3083 
 
 1906 
 
 4308 
 
 1911 
 
 3725 
 
 1573 
 
 1355 
 
 3544 
 
 1365 
 
 2923 
 
 1885 
 
 3211 
 
 2097 
 
 3113 
 
 1901 
 
 878 
 
 3532 
 
 951 
 
 2914 
 
 1907 
 
 4429 
 
 1940 
 
 3949 
 
 1651 
 
 1422 
 
 3663 
 
 1390 
 
 2939 
 
 1886 
 
 3283 
 
 2103 
 
 3194 
 
 1912 
 
 870 
 
 3424 
 
 992 
 
 2988 
 
 1908 
 
 4144 
 
 1793 
 
 3730 
 
 1544 
 
 1317 
 
 3341 
 
 1244 
 
 2598 
 
 1887 
 
 3250 
 
 2042 
 
 3130 
 
 1838 
 
 942 
 
 3627 
 
 1050 
 
 3109 
 
 1909 
 
 4073 
 
 1742 
 
 3718 
 
 1525 
 
 1321 
 
 3302 
 
 1264 
 
 2607 
 
 1888 
 
 3578 
 
 2102 
 
 3316 
 
 1786 
 
 988 
 
 3540 
 
 1054 
 
 2944 
 
 1910 
 
 4236 
 
 1791 
 
 3910 
 
 1589 
 
 1352 
 
 3330 
 
 1255 
 
 2557 
 
 1889 
 
 3436 
 
 1982 
 
 3383 
 
 1791 
 
 913 
 
 3209 
 
 971 
 
 2668 
 
 1911 
 
 4141 
 
 1731 
 
 3618 
 
 1458 
 
 1351 
 
 3279 
 
 1294 
 
 2606 
 
 1890 
 
 4112 
 
 2329 
 
 3914 
 
 2038 
 
 1047 
 
 3610 
 
 1125 
 
 3041 
 
 1912 
 
 4190 
 
 1732 
 
 3690 
 
 1474 
 
 1362 
 
 3259 
 
 1199 
 
 2386 
 
 1891 
 
 4055 
 
 2256 
 
 3783 
 
 1939 
 
 1065 
 
 3604 
 
 1170 
 
 3112 
 
 1913 
 
 4043 
 
 1653 
 
 3807 
 
 1509 
 
 1201 
 
 2834 
 
 1117 
 
 2197 
 
 1892 
 
 4301 
 
 2352 
 
 4060 
 
 2048 
 
 1105 
 
 3670 
 
 1116 
 
 2921 
 
 1914 
 
 4219 
 
 1708 
 
 3695 
 
 1453 
 
 1368 
 
 3183 
 
 1269 
 
 2468 
 
 1893 
 
 3741 
 
 2011 
 
 3629 
 
 1803 
 
 1105 
 
 3603 
 
 1079 
 
 2780 
 
 1915 
 
 3962 
 
 1587 
 
 3563 
 
 1390 
 
 1302 
 
 2989 
 
 1175 
 
 2260 
 
 1894 
 
 3731 
 
 1972 
 
 3511 
 
 1719 
 
 1087 
 
 3480 
 
 1157 
 
 2939 
 
 1916 
 
 4256 
 
 1688 
 
 3727 
 
 1444 
 
 1400 
 
 3171 
 
 1336 
 
 2542 
 
 1895 
 
 4069 
 
 2116 
 
 3815 
 
 1841 
 
 1213 
 
 3814 
 
 1204 
 
 3008 
 
 1917 
 
 4513 
 
 1773 
 
 3849 
 
 1481 
 
 1639 
 
 3663 
 
 1363 
 
 2566 
 
 1896 
 
 3956 
 
 2024 
 
 3656 
 
 1739 
 
 1140 
 
 3521 
 
 1167 
 
 2872 
 
 1918 
 
 6632 
 
 2581 
 
 5680 
 
 2170 
 
 1873 
 
 4132 
 
 1847 
 
 3441 
 
 1897 
 
 3760 
 
 1894 
 
 3403 
 
 1597 
 
 1091 
 
 3311 
 
 1075 
 
 2607 
 
 1919 
 
 4637 
 
 1509 
 
 4253 
 
 1373 
 
 1328 
 
 2774 
 
 1216 
 
 2156 
 
 1898 
 
 4102 
 
 2034 
 
 3806 
 
 1763 
 
 1218 
 
 3633 
 
 1259 
 
 3009 
 
 1920 
 
 4428 
 
 1436 
 
 4351 
 
 1374 
 
 1263 
 
 2371 
 
 1314 
 
 2368 
 
 1899 
 
 3982 
 
 1945 
 
 3782 
 
 1728 
 
 1187 
 
 3480 
 
 1201 
 
 2829 
 
 
 
 
 
 
 
 
 
 
 1876-1880, and 3,668 for 1881-1885. In the meantime, on its much lower 
 level the rate for whites had been declining since 1875. For the 20 years 
 between 1886 and 1905, the rate for negroes held nearly constant around 
 3,200, while the rate for whites was undergoing a considerable decline. For 
 the quinquennium 1911-1915 the rate for negroes fell to 2,713, to rise to 
 2,893 for that ending in 1920. The period under consideration ends, then, 
 with a rate for negroes higher than between 1841-1845, and 1856-1870. 
 
 Data for the study of the influence of sex in respect of race upon the mor¬ 
 tality from all causes are available since 1878, and are represented in tables 
 134 and 135 and graph 37. During this period there has been a striking 
 difference in favor of females. It will be observed that the rates for females 
 have been uniformly lower than those for males, and it is notable that, with 
 
GENERAL CONCLUSIONS 
 
 515 
 
 the annual rates with a few exceptions and with the rates as averaged for 
 5-year periods without exception, the mortality for the two sexes in both 
 races rose and fell together. Among whites, the difference between the rates 
 
 Table 135 .—Average rate of death, per 100,000 living inhabi¬ 
 tants, by 5-year periods, from all caiLses, by color and 
 sex, from 1878 to 1920, inclusive. 
 
 Period. 
 
 White. 
 
 Colored. 
 
 Male. 
 
 Fem. 
 
 Male. 
 
 Fem. 
 
 1878-80 . 
 
 2137 
 
 1955 
 
 3765 
 
 3093 
 
 1881-85 . 
 
 2343 
 
 2065 
 
 4112 
 
 3332 
 
 1886-90 . 
 
 2112 
 
 1873 
 
 3482 
 
 2950 
 
 1891-95 . 
 
 2141 
 
 1870 
 
 3634 
 
 2952 
 
 1896-1900 . 
 
 1982 
 
 1719 
 
 3510 
 
 2893 
 
 1901-05 . 
 
 1908 
 
 1624 
 
 3606 
 
 2910 
 
 1906-10 . 
 
 1835 
 
 1576 
 
 3436 
 
 2725 
 
 1911-15 . 
 
 1722 
 
 1457 
 
 3109 
 
 2383 
 
 1916-20 . 
 
 1797 
 
 1568 
 
 3222 
 
 2615 
 
 Graph 37 (from table 134). Annual mortality-rates from all causes, by color 
 
 and sex, from 1878 to 1920, inclusive. 
 
 for males and females was less marked before 1885 and after 1918 than in 
 the intermediate period. Throughout the latter, especially when judged by 
 the averaged rates, the difference between the level of the two rates is singu¬ 
 larly uniform. Among negroes, except in a few years, notably 1878 and 1920, 
 
516 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 when the rates for males and females approximated each other closely and 
 in a few other years when they deviated somewhat more sharply than usual, 
 the difference in mortality for the two sexes was very uniform. 
 
 Between 1814 and 1920, inclusive, and in unbroken series, the distribution 
 of deaths according to the age of the decedents is recorded annually in the 
 official records of the health department under the same age-groupings, 0 to 
 1, between 1 and 2, between 2 and 4, under 5, and between 5 and 9 years, and 
 thereafter by decades of life. Deaths by age, sex, and color are recorded for 
 1910 and 1920. On account of the questionable accuracy of the estimated 
 figures for these age-groups of the population in certain years (see chapter 
 on population), the enormous amount of work involved in the necessary calcu¬ 
 lations, and the great expense of printing such voluminous tables, it is imprac¬ 
 ticable to present here mortality-rates specific for age for the inter-censal 
 years. So important in some ways and so unique are these data that after 
 studying rates specific for these age-groupings for the census years 1830 to 
 1920, they will be considered in their proportional relation to the whole num¬ 
 ber of annual deaths and such correspondences in the trends of these figures 
 and the specific rates as may appear will be pointed out. 
 
 Bates specific for age for the whole population in the several census years 
 1830 to 1920, inclusive, are given in table 136 and graph 38. As the popula¬ 
 tion figures for certain of the age-groups in 1830 and 1840, 1870, 1880, and 
 1890 were estimated (see table 10), the resulting rates must be regarded as 
 only approximately correct. In regard to the first year of life, it will be 
 observed that the rate rose somewhat gradually from 16,697 in 1850 to 28,640 
 in 1890, and then fell for each successive decennium to 13,197 in 1920. In 
 the age-group 0 to 4 years the rate, after falling from 7,232 in 1830 to 5,891 
 in 1840, rose to a peak of 10,631 in 1870, and thereafter fell continuously 
 to 4,107 in 1920. In order of sequence, the highest rates occurred in 1870, 
 1880, 1890, 1850, 1860, and 1830, and the lowest in 1840, 1910, and 1920. 
 In the age-period 5 to 9 years the rate, after falling from 1,164 in 1830 to 836 
 in 1840, and reacting to 1,311 in 1850, fell to 911 in 1860, and then rising 
 to its peak of 1,502 in 1880, by 1920 had declined to 313, a difference in the 
 extremes even more striking than in the other two categories. In these age- 
 groups, then, the rates fell significantly between 1830 and 1840, rose markedly 
 between 1840 and 1870 or 1880, and declined in even greater degree between 
 these dates and 1920. Consequently in the first decade of life, a like dispro¬ 
 portion existed between the rates for 1840 and 1870 and between those of 
 1880 and 1920. 
 
 In the second decade of life, when, for each particular census year without 
 exception the mortality was lightest, the rates stood in order of their high 
 levels, 1850, 1870, 1860, 1830, and 1880, and their low levels, 1890, 1840, 
 1900, 1910, and 1920. Between 1850 and 1880, the recession was compara¬ 
 tively slight, while that between 1880 and 1920 was marked, and the declines for 
 each succeeding decennium were in ever-increasing ratio. For the third decade 
 of life the mortality was highest in 1850, 1830, 1870, 1880, and 1890, and 
 lowest in 1840, 1900, 1910, and 1920. For the fourth decade the sequence of 
 high rates according to years was 1830, 1850, 1840, 1870, 1890, 1880, 1860 
 and of the low rates 1900, 1910, and 1920. Whatever the changes among the 
 others may have been, up to this age-group, 1900, 1910, and 1920, and, 
 
GENERAL CONCLUSIONS 
 
 517 
 
 Table 136 .—Number of deaths and rate of death, per 100,000 living inhabitants, from all causes, 
 according to age for the census years 1830, 18Jfi, 1850, 1860, 1870, 1880, 1890, and 1900, and 
 according to age, sex, and color for 1910 and 1920. 
 
 D = death. R = rate. 
 
 Age-groups. 
 
 1830 
 
 1840 
 
 1850 
 
 1860 
 
 1870 
 
 1880 
 
 1890 
 
 1900 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 Under 1 year. 
 
 Between 1 and 2 years . 
 
 2 to 4 years. 
 
 0 to 4 years. 
 
 5 to 9 years. 
 
 0 to 9 years. 
 
 10 to 19 years. 
 
 20 to 29 years. 
 
 30 to 39 years. 
 
 40 to 49 years. 
 
 50 to 59 years. 
 
 60 to 69 vears. 
 
 70 to 79 years. 
 
 80 years and over. 
 
 Total. 
 
 406 
 
 184 
 
 232 
 
 822 
 
 110 
 
 933 
 
 123 
 
 193 
 
 202 
 
 214 
 
 126 
 
 85 
 
 57 
 
 42 
 
 • • • • 
 
 7232 
 
 1164 
 
 4478 
 
 641 
 
 1129 
 
 1855 
 
 3411 
 
 3591 
 
 4874 
 
 6840 
 
 10660 
 
 532 
 
 182 
 
 183 
 
 897 
 
 93 
 
 990 
 
 123 
 
 205 
 
 226 
 
 166 
 
 126 
 
 82 
 
 76 
 
 51 
 
 • • • « 
 
 • • • • 
 
 5891 
 
 806 
 
 3700 
 
 555 
 
 909 
 
 1517 
 
 2085 
 
 2838 
 
 3600 
 
 8889 
 
 11778 
 
 1023 
 544 1 
 488 < 
 2055 
 263 
 2318 
 247 
 399 
 381 
 278 
 220 
 157 
 134 
 
 86 
 
 16697 
 
 5600 
 
 8369 
 
 1311 
 
 5195 
 
 675 
 
 1161 
 
 1551 
 
 1916 
 
 2715 
 
 3813 
 
 8156 
 
 13014 
 
 1227 
 616 | 
 539 ( 
 2382 
 234 
 2616 
 282 
 395 
 418 
 323 
 243 
 260 
 210 
 119 
 
 18813 
 
 4832 
 
 7830 
 
 911 
 
 4662 
 
 643 
 
 975 
 
 1311 
 
 1562 
 
 2155 
 
 4783 
 
 10314 
 
 19070 
 
 2098 
 855 1 
 722 r 
 3675 
 301 
 3976 
 360 
 574 
 562 
 500 
 443 
 385 
 278 
 184 
 
 27806 
 
 5836 
 
 10631 
 
 982 
 
 6096 
 
 662 
 
 1099 
 
 1428 
 
 1837 
 
 2696 
 
 4616 
 
 8533 
 
 20109 
 
 2329 
 701 | 
 572 | 
 3602 
 541 
 4143 
 396 
 663 
 599 
 529 
 529 
 514 
 426 
 244 
 
 27227 
 
 4273 
 
 9394 
 
 1502 
 
 5571 
 
 694 
 
 998 
 
 1249 
 
 1498 
 
 2280 
 
 4203 
 
 8667 
 
 18813 
 
 2740 
 894 | 
 483 f 
 4117 
 441 
 4558 
 479 
 843 
 834 
 784 
 804 
 1085 
 498 
 313 
 
 28640 
 
 3771 
 
 8934 
 
 971 
 
 4981 
 
 562 
 
 960 
 
 1276 
 
 1676 
 
 2645 
 
 6440 
 
 7403 
 
 10493 
 
 2627 
 
 525 
 
 543 
 
 3695 
 
 325 
 
 4020 
 
 483 
 
 916 
 
 947 
 
 952 
 
 959 
 
 1084 
 
 860 
 
 479 
 
 24225 
 
 5599 
 
 1792 
 
 7314 
 
 636 
 
 3956 
 
 490 
 
 904 
 
 1187 
 
 1639 
 
 2648 
 
 5231 
 
 9574 
 
 22094 
 
 1974 
 
 2449 
 
 2045 
 
 1999 
 
 4210 
 
 2490 
 
 4866 
 
 2291 
 
 7262 
 
 2716 
 
 8043 
 
 2420 
 
 10198 
 
 2352 
 
 10700 
 
 2108 
 
 1910 
 
 
 
 
 
 White. 
 
 
 
 
 
 Colored. 
 
 
 
 Age-groups. 
 
 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 Under 1 year. 
 
 2148 
 
 20979 
 
 1566 
 
 17613 
 
 856 
 
 19069 
 
 710 
 
 16129 
 
 582 
 
 43175 
 
 356 
 
 51971 
 
 226 
 
 34087 
 
 Between 1 and 2 years. 
 
 399 
 
 4151 
 
 304 
 
 3583 
 
 161 
 
 3672 
 
 143 
 
 3487 
 
 95 
 
 8429 
 
 52 
 
 9336 
 
 43 
 
 7544 
 
 2 to 4 years. 
 
 344 
 
 1070 
 
 240 
 
 858 
 
 122 
 
 868 
 
 118 
 
 848 
 
 104 
 
 2503 
 
 54 
 
 2684 
 
 50 
 
 2333 
 
 0 to 4 years. 
 
 2891 
 
 5561 
 
 2110 
 
 4652 
 
 1139 
 
 4966 
 
 971 
 
 4331 
 
 781 
 
 11780 
 
 462 
 
 14198 
 
 319 
 
 9449 
 
 5 to 9 years. 
 
 188 
 
 379 
 
 146 
 
 338 
 
 73 
 
 337 
 
 73 
 
 339 
 
 42 
 
 654 
 
 15 
 
 490 
 
 27 
 
 804 
 
 0 to 9 years. 
 
 3079 
 
 3030 
 
 2256 
 
 2548 
 
 1212 
 
 2717 
 
 1044 
 
 2376 
 
 823 
 
 6307 
 
 477 
 
 7555 
 
 346 
 
 5133 
 
 10 to 19 years. 
 
 451 
 
 439 
 
 301 
 
 338 
 
 146 
 
 341 
 
 155 
 
 336 
 
 150 
 
 1089 
 
 62 
 
 1060 
 
 88 
 
 1111 
 
 20 to 29 years. 
 
 883 
 
 781 
 
 570 
 
 617 
 
 289 
 
 650 
 
 281 
 
 586 
 
 313 
 
 1518 
 
 156 
 
 1725 
 
 157 
 
 1356 
 
 30 to 39 years. 
 
 1010 
 
 1131 
 
 686 
 
 934 
 
 393 
 
 1105 
 
 293 
 
 773 
 
 324 
 
 2050 
 
 174 
 
 2275 
 
 150 
 
 1839 
 
 40 to 49 years. 
 
 1094 
 
 1595 
 
 760 
 
 1329 
 
 420 
 
 1524 
 
 340 
 
 1147 
 
 334 
 
 2931 
 
 170 
 
 3006 
 
 164 
 
 2857 
 
 50 to 59 years. 
 
 1256 
 
 2784 
 
 977 
 
 2502 
 
 553 
 
 2929 
 
 424 
 
 2102 
 
 279 
 
 4602 
 
 145 
 
 4899 
 
 134 
 
 4318 
 
 60 to 69 years. 
 
 1352 
 
 5451 
 
 1138 
 
 5192 
 
 628 
 
 6354 
 
 510 
 
 4238 
 
 214 
 
 7410 
 
 100 
 
 7576 
 
 114 
 
 7270 
 
 70 to 79 years. 
 
 1067 
 
 10208 
 
 976 
 
 10320 
 
 427 
 
 10843 
 
 549 
 
 9947 
 
 91 
 
 9137 
 
 45 
 
 11166 
 
 46 
 
 7757 
 
 80 years and over. 
 
 561 
 
 21003 
 
 4S2 
 
 20295 
 
 168 
 
 19580 
 
 314 
 
 20699 
 
 79 
 
 26689 
 
 23 
 
 24731 
 
 56 
 
 27586 
 
 Total. 
 
 10753 
 
 1925 
 
 8146 
 
 1721 
 
 4236 
 
 1851 
 
 3910 
 
 1599 
 
 2607 
 
 3064 
 
 1352 
 
 3433 
 
 1255 
 
 2745 
 
 1920 
 
 Age-groups. 
 
 Total. 
 
 White. 
 
 Colored. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 Total. 
 
 Male. 
 
 Fem. 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 Under 1 year. 
 
 Between 1 and 2 years.. 
 
 2 to 4 years. 
 
 0 to 4 3 'ears. 
 
 5 to 9 years. 
 
 0 to 9 years. 
 
 10 to 19 years. 
 
 20 to 29 years. 
 
 30 to 39 years. 
 
 40 to 49 years. 
 
 50 to 59 years. 
 
 60 to 69 vears. 
 
 70 to 79 vears. 
 
 80 years and over. 
 
 Total. 
 
 1960 
 379 1 
 304 f 
 2643 
 202 
 2845 
 383 
 959 
 1030 
 1174 
 1448 
 1569 
 1325 
 623 
 
 13197 
 
 1253 
 
 4107 
 
 313 
 
 2126 
 
 310 
 
 662 
 
 842 
 
 1271 
 
 2314 
 
 4357 
 
 9192 
 
 17902 
 
 1490 
 270 ) 
 227 i 
 1987 
 161 
 2148 
 266 
 642 
 693 
 809 
 1110 
 1321 
 1216 
 574 
 
 11565 
 
 1033 
 
 3258 
 
 285 
 
 1830 
 
 247 
 
 539 
 
 689 
 
 1054 
 
 2029 
 
 4059 
 
 9312 
 
 18362 
 
 826 
 130 1 
 119 f 
 1075 
 
 94 
 
 1169 
 
 119 
 
 295 
 
 368 
 
 416 
 
 601 
 
 704 
 
 551 
 
 205 
 
 12515 
 
 1031 
 
 3497 
 
 329 
 
 1970 
 
 225 
 
 502 
 
 730 
 
 1089 
 
 2252 
 
 4600 
 
 9845 
 
 18255 
 
 664 
 140 | 
 108 f 
 912 
 
 67 
 
 979 
 
 147 
 
 347 
 
 325 
 
 393 
 
 509 
 
 617 
 
 665 
 369 
 
 10567 
 
 1035 
 
 3016 
 
 241 
 
 1686 
 
 267 
 
 576 
 
 648 
 
 1019 
 
 1816 
 
 3580 
 
 8913 
 
 18422 
 
 470 
 109 | 
 77 ( 
 656 
 
 41 
 
 697 
 
 117 
 
 317 
 
 337 
 365 
 
 338 
 248 
 109 
 
 49 
 
 23882 
 
 29C3 
 
 7833 
 
 508 
 
 4239 
 
 734 
 
 1227 
 
 1544 
 
 2343 
 
 4301 
 
 7157 
 
 8038 
 
 13842 
 
 258 
 561 
 37 j 
 351 
 
 23 
 
 374 
 
 39 
 
 147 
 
 168 
 
 182 
 
 161 
 
 115 
 
 57 
 
 20 
 
 26959 
 
 2987 
 
 8624 
 
 596 
 
 4716 
 
 552 
 
 1206 
 
 1520 
 
 2197 
 
 3793 
 
 6713 
 
 9421 
 
 14925 
 
 212 
 
 53 I 
 40 j 
 305 
 
 18 
 
 323 
 
 78 
 
 170 
 
 169 
 
 183 
 
 177 
 
 133 
 
 52 
 
 29 
 
 20969 
 
 2823 
 
 7085 
 * 428 
 3794 
 878 
 1246 
 1570 
 2510 
 4899 
 7591 
 6924 
 13182 
 
 11356 
 
 1548 
 
 8780 
 
 1405 
 
 4429 
 
 1436 
 
 4351 
 
 1373 
 
 2577 
 
 2371 
 
 1263 
 
 2372 
 
 1314 
 
 2369 
 
518 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 through the first three decades of life, 1840, held steadily the same relative 
 positions as years of low rates and invariably registered the lowest mortality. 
 With the fifth decade of life there began a notable rearrangement, through 
 which, finally, with advancing age, though in rather irregular progression, 
 relative to each other the rates in the earlier census years fell and those in the 
 latter rose to high levels. In consequence, it appears as a general law that 
 when the force of mortality was strongest in the first four decades it generally 
 weakened during the remainder of life, and, conversely, that when this force 
 was relatively less vigorous in early life, it gained in strength proportionately 
 after middle life. 
 
 Graph 38 (from table 136). Mortality-rates from all causes, specific for 
 age in the whole population, for the census years 1830, 1850, 1900 and 
 1920. 
 
 From table 136 and graph 38 it is very evident that the rate for the age- 
 group below the tenth year, which during the whole period until after 1910 
 carried the highest mortality of any decade of life under the sixth, rose on the 
 whole between 1830 and 1870 and thereafter declined continuously. For the 
 second half of this age-group, namely, from 5 to 9 years, the mortality-rate, 
 after fluctuating rather widely between 1830 and 1860 and during these 
 30 years following closely that for the third decade of life, rose abruptly from 
 1860 to 1880, when it surpassed that for the fifth decade. After 1880 it fell 
 sharply, and by 1920 it was but little higher than that for the second decade 
 of life. The rate for the first demi-decade, 0 to 4 years, higher between 1870 
 and 1890 than that for the eighth decade of life, declined markedly after 1870. 
 For the first year of life the rate rose slightly between 1850 and 1860, sharply 
 between 1860 and 1870, reached its peak in 1890 and fell gradually until 
 
GENERAL CONCLUSIONS 
 
 519 
 
 1910 and conspicuously between 1910 and 1920. Except for the slight drop 
 between 1830 and 1840, the mortality-rates for the second and third decades 
 showed but little change from 1830 to 1890, but between the latter date and 
 1920 the fall was considerable in each case. In the fourth decade the death- 
 rate fell notably from 1830 to 1860, but for the next 30 years it ran an almost 
 level course; with but a slight drop between 1890 and 1910, in the last 10 
 years there was a conspicuous decline. In the fifth decade the rate declined 
 considerably, and but for a reaction in 1870, steadily, from 1830 to 1880; 
 rising in 1890 to a level higher than in 1860, and remaining almost stationary 
 for the next 30 years, the rate fell to its lowest point in 1920. For the sixth 
 decade the mortality-rate fell in considerable degree from 1830 to 1860, but 
 from the latter date, except for a decline in 1870, the trend was continuously 
 upwards during the succeeding 50 years, and by 1910 the rate was higher 
 than in 1850. The slight decline between 1910 and 1920 failed to lower the 
 rate to the level of 1860. The course of the rate of the seventh decade was 
 characterized by great instability. Falling markedly from 1830 to 1840 and 
 then rising by 1860 to near the level of 1830, it again declined until 1880. 
 Reaching a high peak in 1890, by 1920 it had fallen to a level but slightly 
 higher than that obtaining in 1880. For the age-groups over 70 years the 
 mortality-rates, while pursuing a somewhat irregular course, w’ere considerably 
 higher in 1920 than in 1830. It is noteworthy that between 1910 and 1920 
 every age-group and between 1830 and 1840 all, but the two highest, showed 
 distinct declines. 
 
 On the whole, during the 90 years between 1830 and 1920, the several age- 
 groups above the fiftieth year exhibited no fall in mortality. In extreme old 
 age the trend of mortality was distinctly upward. In all of the age-groups 
 below the fiftieth year decided declines occurred. Among the latter, except 
 for age-group 40 to 49 years, all substantial recessions in mortality have taken 
 place since 1870. This phenomenon is well illustrated by a comparison of the 
 courses of the rates in the various census years for the population above and 
 below the fortieth year of life with those for the whole population. This is 
 done in table 137. Here the determining influence of the decline in mortality 
 under the fortieth year upon that for all ages since 1870 is brought out very 
 clearly. The failure of any decline in the force of mortality in the remainder 
 of the population is equally evident. As in the natural order all must die, 
 no considerable decrease in the rate of death for the age-groups above the 
 fortieth year can be predicated; but the point here made clear is that between 
 1830 and 1920 for this age-group as a whole there was no extension, but rather 
 a decline in the duration of life, and for the age-group below the fortieth year, 
 while no decline in the death-rate occurred between 1830 and 1870, since the 
 latter date it has fallen by nearly 60 per cent. 
 
 Data for the calculation of rates specific for age, color, and sex are available 
 for 1910 and 1920 (table 136). In 1910, when among both whites and negroes 
 the rates for males was considerably higher than for females, the mortality 
 was greater among whites for males than for females in all the age-groups 
 except 5 to 9 and 80 years and over, and among negroes in males for every 
 age-group except 5 to 9, 10 to 19, and 80 years and over. This excess of male 
 mortality was particularly marked in the whites in the first, fifth, sixth, and 
 seventh, and in negroes in the first, third, and eighth decades of life. In 1920, 
 
520 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 when the differences between the rates for all ages in the two sexes of both 
 races was comparatively slight, the rates were higher in males than in females 
 in all the age-groups among whites, except in the third decade and 80 years 
 and over, and among negroes in females than in males except the first and 
 eighth decades and 80 years and over. In both years mortality was higher in 
 negroes than in whites in all age-groups except in the eighth decade. This 
 difference in favor of the white was greatest below the fiftieth year of life, 
 and in the earlier age-groups amounted to from 100 to 150 per cent. In every 
 
 Table 137 .—Number of deaths and rate of death, per 100,000 
 living inhabitants, specific for the total number, those under 
 40 years of age, and those 40 years of age and over, for the 
 decennia 1830 to 1920, inclusive.* 
 
 Decennia. 
 
 Total. 
 
 Under 40 years. 
 
 40 years and 
 over. 
 
 D 
 
 R 
 
 D 
 
 R 
 
 D 
 
 R 
 
 1830 . 
 
 1967 
 
 2440 
 
 1454 
 
 2139 
 
 513 
 
 2265 
 
 1840 . 
 
 2184 
 
 2135 
 
 1675 
 
 1940 
 
 509 
 
 3188 
 
 1850 . 
 
 4181 
 
 2473 
 
 3264 
 
 2329 
 
 917 
 
 3167 
 
 1860 . 
 
 4776 
 
 2248 
 
 3669 
 
 2129 
 
 1107 
 
 2764 
 
 1870 . 
 
 6970 
 
 2607 
 
 5281 
 
 2501 
 
 1689 
 
 3008 
 
 1880 . 
 
 8159 
 
 2455 
 
 5904 
 
 2312 
 
 2255 
 
 2930 
 
 1890 . 
 
 9658 
 
 2228 
 
 6235 
 
 1890 
 
 3423 
 
 3300 
 
 1900 . 
 
 10443 
 
 2058 
 
 6041 
 
 1584 
 
 4402 
 
 3489 
 
 1910 . 
 
 10511 
 
 1884 
 
 5363 
 
 1320 
 
 5148 
 
 3395 
 
 1920 . 
 
 11395 
 
 1553 
 
 5305 
 
 1011 
 
 6090 
 
 2917 
 
 * The number of deaths for each decennium is a 3-year average 
 of that obtaining in the decennial year and in those years im¬ 
 mediately preceding and following, except in 1920 when the 
 average is for 1919 and 1920 only. 
 
 age-group the mortality was greater for negro males than for white males and 
 females, and for negro females than for white males, except in the eighth 
 decade, and for white females except in the age-period 80 years and over in 1920. 
 
 The proportional distribution of deaths at different ages to the total deaths 
 at all ages for each year from 1814 to 1920 will now be studied. The number 
 of deaths for each of these age-groups and their ratio per hundred to the 
 total deaths at all ages are given for individual years in table 138 and as 
 averaged for 5- and 10-year periods in table 139. In addition, in these tables 
 are presented the number and proportion of deaths recorded as occurring 
 under (before) the fifth and tenth, twentieth, thirtieth, fortieth, fiftieth, 
 sixtieth, and seventieth years of life, and 70 years and over. In the consid¬ 
 eration of this material it is necessary to bear constantly in mind exactly what 
 it does and does not represent, for otherwise conclusions open to serious errors 
 may be drawn. The figures in the percentages columns indicate solely the propor¬ 
 tion in any given period of time of all the decedents of all ages that fell 
 within certain age-groups. The number of living individuals in the popula¬ 
 tion subject to the risk of death was never, of course, evenly distributed in 
 respect to age-groupings, and the proportional distribution of living individ- 
 
Table 138.— Percentage, by separate years, of deaths by specified age-^periods of total deaths 
 
 from all causes, from 1814 to 1920, inclusive. 
 
 1 
 
 Year. 
 
 Under 1 
 vear. 
 
 Between 
 
 1 and 2 
 years. 
 
 Under 2 
 years. 
 
 2 to 4 
 years. 
 
 Under 5 
 years. 
 
 5 to 9 
 years. 
 
 Under 
 
 10 years. 
 
 10 to 19 
 years. 
 
 20 to 29 
 years. 
 
 30 to 39 
 years. 
 
 Deaths. 
 
 Per cent of 
 total deaths. 
 
 — 
 
 Deaths. 
 
 Per cent of 
 total deaths. 
 
 Deaths. 
 
 Per cent of 
 
 total deaths. 
 
 Deaths. 
 
 Per cent of 
 
 total deaths. 
 
 Deaths. 
 
 Per cent of 
 
 total deaths. 
 
 Deaths. 
 
 Per cent of 
 
 total deaths. 
 
 Deaths. 
 
 Per cent of 
 
 total deaths. 
 
 Deaths. 
 
 Per cent of 
 
 total deaths. 
 
 Deaths. 
 
 Per cent of 
 
 total deaths. 
 
 Deaths. 
 
 Per cent of 
 total deaths. 
 
 1814 
 
 • • 
 
 249 
 
 21.6 
 
 115 
 
 10.0 
 
 364 
 
 31.6 
 
 70 
 
 6.1 
 
 434 
 
 37.7 
 
 41 
 
 3.6 
 
 475 
 
 41.2 
 
 76 
 
 6.6 
 
 179 
 
 15.5 
 
 167 
 
 14.5 
 
 1815 
 
 • • 
 
 448 
 
 33.2 
 
 73 
 
 5.4 
 
 521 
 
 38.6 
 
 92 
 
 I 6.8 
 
 613 
 
 45.4 
 
 70 
 
 6.2 
 
 683 
 
 50.6 
 
 192 
 
 14.2 
 
 174 
 
 12.9 
 
 107 
 
 7.9 
 
 1816 
 
 • • 
 
 477 
 
 36.2 
 
 73 
 
 5.5 
 
 550 
 
 41.8 
 
 104 
 
 7.9 
 
 654 
 
 49.7 
 
 54 
 
 4.1 
 
 708 
 
 63.8 
 
 166 
 
 12.6 
 
 176 
 
 13.4 
 
 102 
 
 7.7 
 
 1817 
 
 • • 
 
 430 
 
 ! 32.5 
 
 141 
 
 10.7 
 
 571 
 
 43.1 
 
 59 
 
 4.5 
 
 630 
 
 47.6 
 
 39 
 
 3.0 
 
 669 
 
 50.5 
 
 108 
 
 8.2 
 
 198 
 
 15.0 
 
 133 
 
 10.1 
 
 1818 
 
 « . 
 
 499 
 
 29.1 
 
 190 
 
 11.1 
 
 689 
 
 40.2 
 
 63 
 
 3.1 
 
 742 
 
 43.2 
 
 62 
 
 3.6 
 
 804 
 
 46.9 
 
 154 
 
 9.0 
 
 251 
 
 14.6 
 
 210 
 
 12.2 
 
 1819 
 
 # • 
 
 516 
 
 23.7 
 
 252 
 
 11.6 
 
 768 
 
 35.2 
 
 129 
 
 5.9 
 
 897 
 
 41.1 
 
 147 
 
 6.7 
 
 1044 
 
 47.9 
 
 291 
 
 13.3 
 
 357 
 
 16.4 
 
 191 
 
 8.8 
 
 1820 
 
 • • 
 
 390 
 
 25.5 
 
 116 
 
 7.6 
 
 506 
 
 33.1 
 
 48 
 
 3.1 
 
 554 
 
 36.3 
 
 77 
 
 5.0 
 
 631 
 
 41.3 
 
 113 
 
 7.4 
 
 177 
 
 11.6 
 
 210 
 
 13.8 
 
 1821 
 
 • • 
 
 323 
 
 16.9 
 
 134 
 
 7.0 
 
 457 
 
 23.9 
 
 116 
 
 6.1 
 
 573 
 
 30.0 
 
 87 
 
 4.6 
 
 660 
 
 34.6 
 
 170 
 
 8.9 
 
 247 
 
 12.9 
 
 283 
 
 14.8 
 
 1822 
 
 • • 
 
 347 
 
 15.8 
 
 154 
 
 7.0 
 
 501 
 
 22.8 
 
 114 
 
 5.2 
 
 615 
 
 28.0 
 
 91 
 
 4.1 
 
 706 
 
 32.1 
 
 232 
 
 10.6 
 
 325 
 
 14.8 
 
 341 
 
 15.5 
 
 1823 
 
 # , 
 
 366 
 
 18.3 
 
 200 
 
 10.0 
 
 566 
 
 28.3 
 
 253 
 
 12.7 
 
 819 
 
 41.0 
 
 116 
 
 5.8 
 
 935 
 
 46.8 
 
 149 
 
 7.5 
 
 174 
 
 8.7 
 
 236 
 
 11.8 
 
 1824 
 
 # . 
 
 310 
 
 22.7 
 
 78 
 
 5.7 
 
 388 
 
 28.4 
 
 106 
 
 7.8 
 
 494 
 
 36.2 
 
 57 
 
 4.2 
 
 551 
 
 40.3 
 
 112 
 
 8.2 
 
 139 
 
 10.2 
 
 164 
 
 12.0 
 
 1825 
 
 . # 
 
 316 
 
 21.8 
 
 114 
 
 7.9 
 
 430 
 
 29.6 
 
 103 
 
 7.1 
 
 533 
 
 36.7 
 
 54 
 
 3.7 
 
 587 
 
 40.4 
 
 94 
 
 6.5 
 
 170 
 
 11.7 
 
 190 
 
 13.1 
 
 1826 
 
 
 412 
 
 22.6 
 
 171 
 
 9.4 
 
 583 
 
 32.0 
 
 138 
 
 7.6 
 
 721 
 
 39.5 
 
 71 
 
 3.9 
 
 792 
 
 43.4 
 
 117 
 
 6.4 
 
 178 
 
 9.8 
 
 230 
 
 12.6 
 
 1827 
 
 
 360 
 
 25.8 
 
 100 
 
 7.2 
 
 460 
 
 32.9 
 
 102 
 
 7.3 
 
 562 
 
 40.2 
 
 59 
 
 4.2 
 
 621 
 
 44.4 
 
 94 
 
 6.7 
 
 133 
 
 9.5 
 
 167 
 
 12.0 
 
 1828 
 
 
 435 
 
 27.0 
 
 134 
 
 8.3 
 
 569 
 
 35.3 
 
 149 
 
 9.2 
 
 718 
 
 44.5 
 
 53 
 
 3.3 
 
 771 
 
 47.8 
 
 87 
 
 5.4 
 
 152 
 
 9.4 
 
 156 
 
 9.7 
 
 1829 
 
 # # 
 
 428 
 
 24.6 
 
 126 
 
 7.2 
 
 554 
 
 31.8 
 
 167 
 
 9.6 
 
 721 
 
 41.4 
 
 55 
 
 3.2 
 
 776 
 
 44.5 
 
 111 
 
 6.4 
 
 177 
 
 10.2 
 
 188 
 
 10.8 
 
 1830 
 
 
 406 
 
 20.6 
 
 184 
 
 9.3 
 
 590 
 
 29.9 
 
 232 
 
 11.8 
 
 822 
 
 41.6 
 
 110 
 
 5.6 
 
 932 
 
 47.2 
 
 123 
 
 6.2 
 
 193 
 
 9.8 
 
 202 
 
 10.2 
 
 1831 
 
 
 514 
 
 23.5 
 
 166 
 
 7.6 
 
 680 
 
 31.1 
 
 244 
 
 11.2 
 
 924 
 
 42.3 
 
 125 
 
 5.7 
 
 1049 
 
 48.0 
 
 147 
 
 6.7 
 
 225 
 
 10.3 
 
 248 
 
 11.4 
 
 1832 
 
 
 652 
 
 19.0 
 
 222 
 
 6.5 
 
 874 
 
 25.5 
 
 241 
 
 7.0 
 
 1115 
 
 32.5 
 
 117 
 
 3.4 
 
 1232 
 
 36.0 
 
 240 
 
 7.0 
 
 409 
 
 11.9 
 
 507 
 
 14.8 
 
 1833 
 
 , , 
 
 625 
 
 27.4 
 
 224 
 
 9.8 
 
 849 
 
 37.3 
 
 274 
 
 12.0 
 
 1123 
 
 49.3 
 
 124 
 
 5.4 
 
 1247 
 
 54.7 
 
 136 
 
 6.0 
 
 213 
 
 9.4 
 
 228 
 
 10.0 
 
 1834 
 
 • • 
 
 616 
 
 23.7 
 
 240 
 
 9.2 
 
 856 
 
 32.9 
 
 267 
 
 10.3 
 
 1123 
 
 43.2 
 
 117 
 
 4.5 
 
 1240 
 
 47.7 
 
 172 
 
 6.6 
 
 289 
 
 11.1 
 
 299 
 
 11.5 
 
 1835 
 
 • • 
 
 461 
 
 24.3 
 
 176 
 
 9.3 
 
 637 
 
 33.6 
 
 141 
 
 7.4 
 
 778 
 
 41.0 
 
 58 
 
 3.1 
 
 836 
 
 44.1 
 
 120 
 
 6.3 
 
 189 
 
 10.0 
 
 223 
 
 11.8 
 
 1836 
 
 • • 
 
 584 
 
 26.6 
 
 180 
 
 8.2 
 
 764 
 
 34.9 
 
 208 
 
 9.5 
 
 972 
 
 44.3 
 
 78 
 
 3.6 
 
 1050 
 
 47.9 
 
 109 
 
 5.0 
 
 203 
 
 9.3 
 
 227 
 
 10.4 
 
 1837 
 
 • • 
 
 630 
 
 25.0 
 
 275 
 
 10.9 
 
 905 
 
 35.9 
 
 324 
 
 12.9 
 
 1229 
 
 48.8 
 
 148 
 
 5.9 
 
 1377 
 
 54.7 
 
 172 
 
 6.8 
 
 217 
 
 8.6 
 
 250 
 
 9.9 
 
 1838 
 
 • • 
 
 655 
 
 26.5 
 
 256 
 
 10.3 
 
 911 
 
 36.8 
 
 246 
 
 9.9 
 
 1157 
 
 46.7 
 
 125 
 
 5.1 
 
 1282 
 
 51.8 
 
 154 
 
 6.2 
 
 238 
 
 9.6 
 
 276 
 
 11.2 
 
 1839 
 
 • • 
 
 612 
 
 27.1 
 
 257 
 
 11.4 
 
 869 
 
 38.5 
 
 266 
 
 11.8 
 
 1135 
 
 50.2 
 
 99 
 
 4.4 
 
 1234 
 
 54.6 
 
 112 
 
 5.0 
 
 189 
 
 8.4 
 
 220 
 
 9.7 
 
 1840 
 
 . , 
 
 532 
 
 26.0 
 
 182 
 
 8.9 
 
 714 
 
 34.9 
 
 183 
 
 9.0 
 
 897 
 
 43.9 
 
 93 
 
 4.6 
 
 990 
 
 48.4 
 
 123 
 
 6.0 
 
 205 
 
 10.0 
 
 226 
 
 11.1 
 
 1841 
 
 
 651 
 
 29.0 
 
 217 
 
 9.7 
 
 868 
 
 38.6 
 
 208 
 
 9.3 
 
 1076 
 
 47.9 
 
 82 
 
 3.7 
 
 1158 
 
 51.5 
 
 123 
 
 5.5 
 
 214 
 
 95 
 
 231 
 
 10.3 
 
 1842 
 
 • • 
 
 666 
 
 26.9 
 
 315 
 
 12.7 
 
 981 
 
 39.6 
 
 263 
 
 10.6 
 
 1244 
 
 50.2 
 
 106 
 
 4.3 
 
 1350 
 
 54.5 
 
 158 
 
 6.4 
 
 225 
 
 9.1 
 
 221 
 
 8.9 
 
 1843 
 
 • • 
 
 682 
 
 29.2 
 
 229 
 
 9.8 
 
 911 
 
 39.0 
 
 153 
 
 6.6 
 
 1064 
 
 45.6 
 
 91 
 
 3.9 
 
 1155 
 
 49.5 
 
 138 
 
 5.9 
 
 251 
 
 10.8 
 
 234 
 
 10.0 
 
 1844 
 
 • • 
 
 630 
 
 23.6 
 
 285 
 
 10.7 
 
 915 
 
 34.3 
 
 363 
 
 13.6 
 
 1278 
 
 48.0 
 
 158 
 
 5.9 
 
 1436 
 
 53.9 
 
 161 
 
 6.0 
 
 212 
 
 8.0 
 
 262 
 
 9.8 
 
 1845 
 
 . , 
 
 830 
 
 28.7 
 
 208 
 
 7.2 
 
 1038 
 
 35.8 
 
 351 
 
 12.1 
 
 1389 
 
 48.0 
 
 149 
 
 5.2 
 
 1538 
 
 53.1 
 
 155 
 
 5.4 
 
 283 
 
 9.8 
 
 305 
 
 10.5 
 
 1846 
 
 # # 
 
 786 
 
 26.3 
 
 287 
 
 9.6 
 
 1073 
 
 35.8 
 
 320 
 
 10.7 
 
 1393 
 
 46.5 
 
 167 
 
 5.6 
 
 1560 
 
 52.1 
 
 200 
 
 6.7 
 
 262 
 
 8.8 
 
 305 
 
 10.2 
 
 1847 
 
 
 866 
 
 25.4 
 
 420 
 
 12.3 
 
 1286 
 
 37.7 
 
 376 
 
 11.0 
 
 1662 
 
 48.7 
 
 173 
 
 5.1 
 
 1835 
 
 53.8 
 
 151 
 
 4.4 
 
 320 
 
 9.4 
 
 .343 
 
 10.1 
 
 1848 
 
 
 959 
 
 24.8 
 
 471 
 
 12.2 
 
 1430 
 
 37.0 
 
 508 
 
 13.2 
 
 1938 
 
 50.2 
 
 220 
 
 5.7 
 
 2158 
 
 55.9 
 
 207 
 
 5.4 
 
 352 
 
 9.1 
 
 349 
 
 9.0 
 
 1849 
 
 , , 
 
 995 
 
 23.9 
 
 500 
 
 12.0 
 
 1495 
 
 35.9 
 
 414 
 
 9.9 
 
 1909 
 
 45.8 
 
 174 
 
 4.2 
 
 2083 
 
 50.0 
 
 237 
 
 5.7 
 
 435 
 
 10.4 
 
 433 
 
 10.4 
 
 1850 
 
 
 1023 
 
 24.3 
 
 544 
 
 12.9 
 
 1567 
 
 37.2 
 
 488 
 
 11.6 
 
 2055 
 
 48.8 
 
 263 
 
 6.3 
 
 2318 
 
 55.1 
 
 247 
 
 5.9 
 
 399 
 
 9.5 
 
 381 
 
 9.1 
 
 1851 
 
 
 1039 
 
 24.9 
 
 496 
 
 11.9 
 
 1535 
 
 36.8 
 
 467 
 
 11.2 
 
 2002 
 
 48.0 
 
 233 
 
 6.6 
 
 2235 
 
 53.6 
 
 206 
 
 4.9 
 
 429 
 
 10.3 
 
 391 
 
 9.4 
 
 1852 
 
 # # 
 
 1203 
 
 24.2 
 
 667 
 
 13.4 
 
 1870 
 
 37.7 
 
 683 
 
 13.8 
 
 2553 
 
 51.4 
 
 315 
 
 6.3 
 
 2868 
 
 57.8 
 
 262 
 
 5.3 
 
 450 
 
 9.1 
 
 394 
 
 7.9 
 
 1853 
 
 , , 
 
 1173 
 
 24.4 
 
 478 
 
 10.0 
 
 1651 
 
 34.4 
 
 595 
 
 12.4 
 
 2246 
 
 46.8 
 
 287 
 
 6.0 
 
 2533 
 
 62.7 
 
 270 
 
 5.6 
 
 457 
 
 9.5 
 
 488 
 
 10.2 
 
 1854 
 
 , # 
 
 1235 
 
 23.1 
 
 656 
 
 12.3 
 
 1891 
 
 35.4 
 
 676 
 
 12.7 
 
 2567 
 
 48.0 
 
 312 
 
 5.8 
 
 2879 
 
 53.9 
 
 284 
 
 5.3 
 
 532 
 
 10.0 
 
 535 
 
 10.0 
 
 1855 
 
 • • 
 
 1306 
 
 25.7 
 
 647 
 
 12.8 
 
 1953 
 
 38.5 
 
 500 
 
 9.9 
 
 2453 
 
 48.3 
 
 249 
 
 4.9 
 
 2702 
 
 53.2 
 
 286 
 
 5.6 
 
 484 
 
 9.5 
 
 462 
 
 9.1 
 
 1856 
 
 • • 
 
 1471 
 
 28.1 
 
 758 
 
 14.5 
 
 2229 
 
 42.6 
 
 528 
 
 10.1 
 
 2757 
 
 52.7 
 
 229 
 
 4.4 
 
 2986 
 
 57.1 
 
 191 
 
 3.7 
 
 458 
 
 8.8 
 
 497 
 
 9.5 
 
 1857 
 
 • • 
 
 1316 
 
 25.7 
 
 713 
 
 13.9 
 
 2029 
 
 39.6 
 
 627 
 
 12.2 
 
 2656 
 
 51.9 
 
 319 
 
 6.2 
 
 2975 
 
 58.1 
 
 244 
 
 4.8 
 
 411 
 
 8.0 
 
 405 
 
 7.9 
 
 1858 
 
 • • 
 
 1283 
 
 23.7 
 
 738 
 
 13.7 
 
 2021 
 
 37.4 
 
 734 
 
 13.6 
 
 2755 
 
 51.0 
 
 388 
 
 7.2 
 
 3143 
 
 58.1 
 
 273 
 
 5.1 
 
 440 
 
 8.1 
 
 424 
 
 7.8 
 
 1859 
 
 • • 
 
 1197 
 
 25.6 
 
 653 
 
 14.0 
 
 1850 
 
 39.6 
 
 553 
 
 11.8 
 
 2403 
 
 51.4 
 
 284 
 
 6.1 
 
 2687 
 
 57.5 
 
 241 
 
 5.2 
 
 354 
 
 7.6 
 
 393 
 
 8.4 
 
 1860 
 
 • • 
 
 1227 
 
 25.2 
 
 616 
 
 12.7 
 
 1843 
 
 37.9 
 
 539 
 
 11.1 
 
 2382 
 
 49.0 
 
 234 
 
 4.8 
 
 2616 
 
 53.8 
 
 282 
 
 5.8 
 
 395 
 
 8.1 
 
 418 
 
 8.6 
 
 1861 
 
 # # 
 
 1178 
 
 24.6 
 
 607 
 
 12.7 
 
 1785 
 
 37.3 
 
 515 
 
 10.8 
 
 2300 
 
 48.0 
 
 278 
 
 5.8 
 
 2578 
 
 53.8 
 
 224 
 
 4.7 
 
 420 
 
 8.8 
 
 399 
 
 8.3 
 
 1862 
 
 
 1105 
 
 21.4 
 
 605 
 
 11.7 
 
 1710 
 
 33.1 
 
 757 
 
 14.6 
 
 2467 
 
 47.7 
 
 440 
 
 8.5 
 
 2907 
 
 56.2 
 
 278 
 
 5.4 
 
 394 
 
 7.6 
 
 390 
 
 7.5 
 
 1863 
 
 # # 
 
 1180 
 
 21.3 
 
 545 
 
 9.8 
 
 1725 
 
 31.1 
 
 814 
 
 14.7 
 
 2539 
 
 45.7 
 
 413 
 
 7.4 
 
 2952 
 
 53.2 
 
 315 
 
 5.7 
 
 494 
 
 8.9 
 
 491 
 
 8.9 
 
 1864 
 
 # # 
 
 1270 
 
 22.4 
 
 623 
 
 11.0 
 
 1893 
 
 33.3 
 
 840 
 
 14.8 
 
 2733 
 
 48.1 
 
 376 
 
 6.6 
 
 3109 
 
 54.8 
 
 333 
 
 5.9 
 
 478 
 
 8.4 
 
 479 
 
 8.4 
 
 1865 
 
 
 1083 
 
 23.1 
 
 384 
 
 8.2 
 
 1467 
 
 31.3 
 
 615 
 
 13.1 
 
 2082 
 
 44.4 
 
 263 
 
 5.6 
 
 2345 
 
 50.0 
 
 269 
 
 5.7 
 
 518 
 
 11.0 
 
 397 
 
 8.5 
 
 1866 
 
 # # 
 
 1285 
 
 22.9 
 
 587 
 
 10.4 
 
 1872 
 
 33.3 
 
 594 
 
 10.6 
 
 2468 
 
 43.9 
 
 294 
 
 6.2 
 
 2760 
 
 49.1 
 
 369 
 
 6.6 
 
 537 
 
 9.6 
 
 487 
 
 8.7 
 
 1867 
 
 # # 
 
 1262 
 
 23.9 
 
 568 
 
 10.8 
 
 1830 
 
 34.6 
 
 622 
 
 11.8 
 
 2452 
 
 46.4 
 
 225 
 
 4.3 
 
 2677 
 
 50.7 
 
 226 
 
 4.3 
 
 519 
 
 9.8 
 
 469 
 
 8.9 
 
 1868 
 
 . m 
 
 1615 
 
 26.1 
 
 778 
 
 12.6 
 
 2393 
 
 38.7 
 
 747 
 
 12.1 
 
 3140 
 
 50.8 
 
 295 
 
 4.8 
 
 3435 
 
 55.6 
 
 241 
 
 3.9 
 
 523 
 
 8.5 
 
 505 
 
 8.2 
 
 1869 
 
 # # 
 
 1710 
 
 26.3 
 
 776 
 
 11.9 
 
 2486 
 
 38.3 
 
 753 
 
 11.6 
 
 3239 
 
 49.9 
 
 345 
 
 5.3 
 
 3584 
 
 55.2 
 
 276 
 
 4.3 
 
 593 
 
 9.1 
 
 490 
 
 7.5 
 
 1870 
 
 • • 
 
 2098 
 
 28.9 
 
 855 
 
 11.8 
 
 2953 
 
 40.7 
 
 722 
 
 9.9 
 
 3675 
 
 50.6 
 
 301 
 
 4.1 
 
 3976 
 
 54.7 
 
 360 
 
 5.0 
 
 574 
 
 7.9 
 
 562 
 
 7.7 
 
 1871 
 
 • • 
 
 1714 
 
 24.0 
 
 892 
 
 12.5 
 
 2606 
 
 36.5 
 
 850 
 
 11.9 
 
 3456 
 
 48.4 
 
 438 
 
 6.1 
 
 3894 
 
 54.5 
 
 414 
 
 5.8 
 
 577 
 
 8.1 
 
 543 
 
 7.6 
 
 1872 
 
 • • 
 
 2090 
 
 23.6 
 
 1067 
 
 12.1 
 
 3157 
 
 35.7 
 
 1020 
 
 11.5 
 
 4177 
 
 47.2 
 
 566 
 
 6.4 
 
 4743 
 
 53.6 
 
 533 
 
 6.0 
 
 843 
 
 9.5 
 
 698 
 
 7.9 
 
 1873 
 
 
 1923 
 
 25.3 
 
 759 
 
 10.0 
 
 2682 
 
 35.3 
 
 611 
 
 8.1 
 
 3293 
 
 43.4 
 
 369 
 
 4.9 
 
 3662 
 
 48.3 
 
 561 
 
 7.4 
 
 679 
 
 9.0 
 
 651 
 
 8.6 
 
 1874 
 
 m m 
 
 2090 
 
 28.3 
 
 857 
 
 11.6 
 
 2947 
 
 39.9 
 
 577 
 
 7.8 
 
 3524 
 
 47.8 
 
 315 
 
 4.3 
 
 3839 
 
 52.0 
 
 435 
 
 5.9 
 
 643 
 
 8.7 
 
 560 
 
 7.6 
 
 1875 
 
 m m 
 
 2216 
 
 30.5 
 
 705 
 
 9.7 
 
 2921 
 
 40.2 
 
 508 
 
 7.0 
 
 3429 
 
 47.2 
 
 373 
 
 5.1 
 
 3802 
 
 52.4 
 
 378 
 
 5.2 
 
 609 
 
 8.4 
 
 560 
 
 7.7 
 
 1876 
 
 
 2317 
 
 30.9 
 
 925 
 
 12.3 
 
 3242 
 
 43.2 
 
 398 
 
 5.3 
 
 3640 
 
 48.6 
 
 424 
 
 5.7 
 
 4064 
 
 54.2 
 
 407 
 
 5.4 
 
 627 
 
 8.4 
 
 528 
 
 7.0 
 
 1877 
 
 
 2182 
 
 27.6 
 
 1329 
 
 16.8 
 
 3511 
 
 44.4 
 
 518 
 
 6.6 
 
 4029 
 
 50.9 
 
 560 
 
 7.1 
 
 4589 
 
 58.0 
 
 423 
 
 6.4 
 
 579 
 
 7.3 
 
 526 
 
 6.7 
 
 1878 
 
 
 1834 
 
 27.2 
 
 604 
 
 9.0 
 
 2438 
 
 36.2 
 
 444 
 
 6.6 
 
 2882 
 
 42.8 
 
 364 
 
 5.4 
 
 3246 
 
 48.2 
 
 356 
 
 5.3 
 
 596 
 
 8.9 
 
 560 
 
 8.3 
 
 1879 
 
 
 2066 
 
 27.1 
 
 762 
 
 10.0 
 
 2828 
 
 37.1 
 
 557 
 
 7.3 
 
 3385 
 
 44.4 
 
 558 
 
 7.3 
 
 3943 
 
 51.8 
 
 347 
 
 4.6 
 
 644 
 
 8.5 
 
 559 
 
 7.3 
 
 1880 
 
 m m 
 
 2329 
 
 29.0 
 
 701 
 
 8.7 
 
 3030 
 
 37.7 
 
 572 
 
 7.1 
 
 3602 
 
 44.8 
 
 541 
 
 6.7 
 
 4143 
 
 51.5 
 
 396 
 
 4.9 
 
 663 
 
 8.2 
 
 599 
 
 7.5 
 
 1881 
 
 
 2364 
 
 26.8 
 
 864 
 
 9.8 
 
 8228 
 
 36.6 
 
 691 
 
 7.8 
 
 3919 
 
 44.5 
 
 665 
 
 7.5 
 
 4584 
 
 52.0 
 
 444 
 
 5.0 
 
 743 
 
 8.4 
 
 647 
 
 7.3 
 
 1882 
 
 
 2198 
 
 24.6 
 
 844 
 
 9.5 
 
 3042 
 
 34.1 
 
 713 
 
 8.0 
 
 3755 
 
 42.1 
 
 800 
 
 9.0 
 
 4555 
 
 51.0 
 
 418 
 
 4.7 
 
 767 
 
 8.6 
 
 667 
 
 7.5 
 
 1883 
 
 
 2351 
 
 25.1 
 
 881 
 
 9.4 
 
 3232 
 
 34.5 
 
 830 
 
 8.9 
 
 4062 
 
 43.3 
 
 796 
 
 8.5 
 
 4858 
 
 51.8 
 
 480 
 
 5.1 
 
 811 
 
 9.7 
 
 746 
 
 8.0 
 
 1884 
 
 
 2354 
 
 28.4 
 
 783 
 
 9.4 
 
 3137 
 
 37.8 
 
 506 
 
 6.1 
 
 3643 
 
 43.9 
 
 472 
 
 5.7 
 
 4115 
 
 50.0 
 
 377 
 
 4.6 
 
 755 
 
 9.1 
 
 633 
 
 7.6 
 
 1885 
 
 
 2196 
 
 26.9 
 
 650 
 
 8.0 
 
 2846 
 
 34.9 
 
 382 
 
 4.7 
 
 3228 
 
 39.6 
 
 363 
 
 4.4 
 
 3591 
 
 44.0 
 
 381 
 
 4.7 
 
 808 
 
 9.9 
 
 698 
 
 8.6 
 
 1886 
 
 
 2393 
 
 28.7 
 
 760 
 
 9.1 
 
 3153 
 
 37.8 
 
 412 
 
 4.9 
 
 3565 
 
 42.8 
 
 347 
 
 4.2 
 
 3912 
 
 47.0 
 
 400 
 
 4.8 
 
 736 
 
 8.8 
 
 720 
 
 8.6 
 
 1887 
 
 
 2420 
 
 28.9 
 
 685 
 
 8.2 
 
 3105 
 
 37.1 
 
 372 
 
 4.4 
 
 3477 
 
 41.5 
 
 307 
 
 3.7 
 
 3784 
 
 45.2 
 
 370 
 
 4.4 
 
 702 
 
 8.4 
 
 708 
 
 8.5 
 
 1888 
 
 
 2624 
 
 29.4 
 
 787 
 
 8.8 
 
 3411 
 
 38.2 
 
 470 
 
 5.3 
 
 3881 
 
 43.4 
 
 345 
 
 3.9 
 
 4226 
 
 47.3 
 
 385 
 
 4.3 
 
 742 
 
 8.3 
 
 715 
 
 8.0 
 
 1889 
 
 
 2578 
 
 29.6 
 
 614 
 
 7.1 
 
 3192 
 
 36.7 
 
 313 
 
 3.6 
 
 3505 
 
 40.3 
 
 321 
 
 3.7 
 
 3826 
 
 44.0 
 
 432 
 
 5.0 
 
 766 
 
 8.8 
 
 720 
 
 8.8 
 
 1890 
 
 , # 
 
 2740 
 
 26.9 
 
 894 
 
 8.8 
 
 3634 
 
 35.6 
 
 483 
 
 4.7 
 
 4117 
 
 40.4 
 
 441 
 
 4.3 
 
 4558 
 
 44.7 
 
 479 
 
 4.7 
 
 843 
 
 8.3 
 
 834 
 
 8.2 
 
 I 
 
 (521) 
 
Table 138.— Percentage, by separate years, of deaths by specified age-periods of total deaths 
 from all causes, from. 1814 to 1920, inclusive. —Continued. 
 
 
 
 Under 1 
 
 Between 
 
 1 and 2 
 years. 
 
 Under 2 
 
 2 to 4 
 
 Under 5 
 
 5 to 9 
 
 Under 
 
 10 to 19 
 
 20 to 29 
 
 30 to 39 
 
 
 
 year. 
 
 years- 
 
 years. 
 
 years. 
 
 years. 
 
 10 years. 
 
 years. 
 
 years. 
 
 years. 
 
 
 
 
 
 
 00 
 
 
 CO 
 
 
 
 
 
 
 CO 
 
 
 
 
 00 
 
 
 GO 
 
 
 TO 
 
 
 
 
 
 
 O te 
 
 
 -■5 
 
 O rt 
 
 
 «4H 
 
 O 
 
 
 «*H 
 
 o 
 
 
 «*H ^ 
 
 ° d 
 
 
 *-< 
 
 o 
 
 
 *H ^ 
 
 o rt 
 
 
 , XX 
 
 o-S 
 
 
 -5 
 
 o <4 
 
 
 
 
 4_j GP 
 
 
 -4-» to 
 
 
 -*-> 0> 
 
 
 -*-> . 
 
 
 -M . 
 
 
 .4J <V 
 
 
 +-> • 
 
 
 0) 
 
 
 ■M 0) 
 
 
 M-. 
 
 
 
 • 
 
 CO 
 
 0Q 
 
 GX 
 
 
 GX 
 
 • 
 
 fl « 
 
 
 e 2 
 
 
 GX 
 
 • 
 
 G “ 
 
 
 C'O 
 
 
 G X) 
 
 • 
 
 G^3 
 
 • 
 
 
 A 
 
 to _ 
 cj 
 
 xx 
 
 O 
 
 « a 
 
 XX 
 
 *-» 
 
 Oh 
 
 o a 
 
 XX 
 
 -*-> 
 
 O) A 
 o 
 
 xx 
 
 -*-> 
 
 4/ A 
 
 XX 
 
 0) r—H 
 
 « d 
 
 XX 
 
 -M 
 
 o> XX 
 
 O Xi 
 
 XX 
 
 4-> 
 
 a)—. 
 
 O a 
 
 XX 
 
 +-> 
 
 O r—t 
 
 v Cj 
 
 XX 
 
 OP — . 
 
 o cj 
 
 d 
 
 
 a 
 
 <v 
 
 t_ -4-> 
 
 5 O 
 
 cj 
 
 <D 
 
 S o 
 
 d 
 
 to 
 
 So 
 
 Cj 
 
 to 
 
 1+ (U 
 
 d 
 
 to 
 
 d 
 
 to 
 
 So 
 
 cj 
 
 O 
 
 Cj 
 
 a> 
 
 
 <D 
 
 Sh 
 
 o> o 
 
 d 
 
 O 
 
 So 
 
 £ 
 
 
 Q 
 
 Cm 
 
 Q 
 
 
 Q 
 
 
 Q 
 
 Q 
 
 Dm' 0 
 
 Q 
 
 
 Q 
 
 Dh ^ 
 
 Q 
 
 Cm 
 
 Q 
 
 Cm 
 
 Q 
 
 Qu 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 1891 
 
 
 2632 
 
 26.1 
 
 732 
 
 7.3 
 
 3364 
 
 33.4 
 
 546 
 
 5.4 
 
 3910 
 
 38.8 
 
 401 
 
 4.0 
 
 4311 
 
 42.8 
 
 445 
 
 4.4 
 
 746 
 
 7.4 
 
 746 
 
 7.4 
 
 1892 
 
 
 2834 
 
 26.8 
 
 886 
 
 8.4 
 
 3720 
 
 35.2 
 
 723 
 
 6.8 
 
 4443 
 
 42.0 
 
 436 
 
 4.1 
 
 4879 
 
 46.1 
 
 464 
 
 4.4 
 
 847 
 
 8.0 
 
 816 
 
 7.7 
 
 1893 
 
 
 2613 
 
 27.4 
 
 585 
 
 6.1 
 
 3198 
 
 33.5 
 
 406 
 
 4.3 
 
 3604 
 
 37.7 
 
 257 
 
 2.7 
 
 3861 
 
 40.4 
 
 505 
 
 5.3 
 
 782 
 
 8.2 
 
 784 
 
 8.2 
 
 1894 
 
 
 2616 
 
 27.6 
 
 669 
 
 7.1 
 
 3285 
 
 34.6 
 
 476 
 
 5.0 
 
 3761 
 
 39.7 
 
 255 
 
 2.7 
 
 4016 
 
 42.3 
 
 459 
 
 4.8 
 
 778 
 
 8.2 
 
 780 
 
 8.2 
 
 1895 
 
 
 2734 
 
 26.5 
 
 739 
 
 7.2 
 
 3473 
 
 33.7 
 
 553 
 
 5.4 
 
 4026 
 
 39.1 
 
 282 
 
 2.7 
 
 4308 
 
 41.8 
 
 480 
 
 4.7 
 
 775 
 
 7.5 
 
 848 
 
 8.2 
 
 1896 
 
 
 2565 
 
 25.9 
 
 633 
 
 6.4 
 
 3198 
 
 32.2 
 
 530 
 
 5.3 
 
 3728 
 
 37.6 
 
 276 
 
 2.8 
 
 4004 
 
 40.4 
 
 452 
 
 4.6 
 
 831 
 
 8.4 
 
 828 
 
 8.4 
 
 1897 
 
 
 2478 
 
 26.6 
 
 546 
 
 5.9 
 
 3024 
 
 32.4 
 
 486 
 
 5.2 
 
 3510 
 
 37.6 
 
 340 
 
 3.6 
 
 3850 
 
 41.3 
 
 430 
 
 4.6 
 
 694 
 
 7.4 
 
 823 
 
 8.8 
 
 1898 
 
 
 2724 
 
 26.2 
 
 580 
 
 5.6 
 
 3304 
 
 31.8 
 
 635 
 
 6.1 
 
 3939 
 
 37.9 
 
 363 
 
 3.5 
 
 4302 
 
 41.4 
 
 479 
 
 4.6 
 
 853 
 
 8.2 
 
 809 
 
 7.8 
 
 1899 
 
 
 2433 
 
 24.0 
 
 409 
 
 4.0 
 
 2842 
 
 28.0 
 
 477 
 
 4.7 
 
 3319 
 
 32.7 
 
 299 
 
 3.0 
 
 3618 
 
 35.6 
 
 510 
 
 5.0 
 
 886 
 
 8.7 
 
 907 
 
 8.9 
 
 1900 
 
 
 2627 
 
 24.6 
 
 525 
 
 4.9 
 
 3152 
 
 29.5 
 
 543 
 
 5.1 
 
 3695 
 
 34.5 
 
 325 
 
 3.0 
 
 4020 
 
 37.6 
 
 483 
 
 4.5 
 
 916 
 
 8.6 
 
 947 
 
 8.9 
 
 1901 
 
 
 2544 
 
 24.3 
 
 449 
 
 4.3 
 
 2993 
 
 28.6 
 
 398 
 
 3.8 
 
 3391 
 
 32.4 
 
 213 
 
 2.0 
 
 3604 
 
 34.4 
 
 422 
 
 4.0 
 
 942 
 
 9.0 
 
 991 
 
 9.5 
 
 1902 
 
 
 2449 
 
 23.9 
 
 466 
 
 4.6 
 
 2915 
 
 28.4 
 
 412 
 
 4.0 
 
 3327 
 
 32.5 
 
 2:33 
 
 2.3 
 
 3560 
 
 34.7 
 
 453 
 
 4.4 
 
 922 
 
 9.0 
 
 894 
 
 8.7 
 
 1903 
 
 
 2174 
 
 21.4 
 
 457 
 
 4.5 
 
 2631 
 
 26.0 
 
 471 
 
 4.6 
 
 3102 
 
 30.6 
 
 260 
 
 2.6 
 
 3362 
 
 33.2 
 
 475 
 
 4.7 
 
 867 
 
 8.6 
 
 920 
 
 9.1 
 
 1904 
 
 
 2289 
 
 21.2 
 
 448 
 
 4.1 
 
 2737 
 
 25.3 
 
 418 
 
 3.9 
 
 3155 
 
 29.2 
 
 257 
 
 2.4 
 
 3412 
 
 31.5 
 
 488 
 
 4.5 
 
 987 
 
 9.1 
 
 986 
 
 9.1 
 
 1905 
 
 
 2457 
 
 23.0 
 
 531 
 
 5.0 
 
 2988 
 
 27.9 
 
 477 
 
 4.5 
 
 3465 
 
 32.4 
 
 202 
 
 1.9 
 
 3667 
 
 34.3 
 
 436 
 
 4.1 
 
 942 
 
 8.8 
 
 975 
 
 9.1 
 
 1906 
 
 
 2418 
 
 22.5 
 
 518 
 
 4.8 
 
 2936 
 
 27.3 
 
 383 
 
 3.6 
 
 3319 
 
 30.9 
 
 228 
 
 2.1 
 
 3547 
 
 33.0 
 
 466 
 
 4.3 
 
 957 
 
 8.9 
 
 977 
 
 9.1 
 
 1907 
 
 
 2423 
 
 21.7 
 
 542 
 
 4.8 
 
 2965 
 
 26.5 
 
 368 
 
 3.3 
 
 3333 
 
 29.8 
 
 206 
 
 1.8 
 
 3539 
 
 31.6 
 
 438 
 
 3.9 
 
 1002 
 
 9.0 
 
 1106 
 
 9.9 
 
 1908 
 
 
 2215 
 
 21.2 
 
 412 
 
 4.0 
 
 2627 
 
 25.2 
 
 340 
 
 3.3 
 
 2967 
 
 28.4 
 
 222 
 
 2.1 
 
 3189 
 
 30.6 
 
 441 
 
 4.2 
 
 910 
 
 8.7 
 
 960 
 
 9.2 
 
 1909 
 
 
 2227 
 
 21.5 
 
 474 
 
 4.6 
 
 2701 
 
 26.0 
 
 370 
 
 3.6 
 
 3071 
 
 29.6 
 
 225 
 
 2.2 
 
 3296 
 
 31.8 
 
 390 
 
 3.8 
 
 915 
 
 8.8 
 
 933 
 
 9.0 
 
 1910 
 
 
 2148 
 
 20.0 
 
 399 
 
 3.7 
 
 2547 
 
 23.7 
 
 344 
 
 3.2 
 
 2891 
 
 26.9 
 
 188 
 
 1.8 
 
 3079 
 
 28.6 
 
 451 
 
 4.2 
 
 883 
 
 8.2 
 
 1010 
 
 9.4 
 
 1911 
 
 
 1958 
 
 18.8 
 
 425 
 
 4.1 
 
 2383 
 
 22.9 
 
 331 
 
 3.2 
 
 2714 
 
 26.1 
 
 205 
 
 2.0 
 
 2919 
 
 28.1 
 
 402 
 
 3.9 
 
 880 
 
 8.5 
 
 933 
 
 9.0 
 
 1912 
 
 
 2026 
 
 19.4 
 
 361 
 
 3.6 
 
 2387 
 
 22.9 
 
 336 
 
 3.2 
 
 2723 
 
 26.1 
 
 171 
 
 1.6 
 
 2894 
 
 27.7 
 
 354 
 
 3.4 
 
 877 
 
 8.4 
 
 992 
 
 9.5 
 
 1913 
 
 . 
 
 2002 
 
 19.7 
 
 399 
 
 3.9 
 
 2401 
 
 23.6 
 
 331 
 
 3.3 
 
 2732 
 
 26.9 
 
 210 
 
 2.1 
 
 2942 
 
 28.9 
 
 327 
 
 3.2 
 
 844 
 
 8.3 
 
 925 
 
 9.1 
 
 1914 
 
 
 1954 
 
 18.5 
 
 394 
 
 3.7 
 
 2348 
 
 22.3 
 
 284 
 
 2.7 
 
 2632 
 
 24.9 
 
 192 
 
 1.8 
 
 2824 
 
 26.8 
 
 351 
 
 3.3 
 
 840 
 
 8.0 
 
 939 
 
 8.9 
 
 1915 
 
 
 1633 
 
 16.3 
 
 300 
 
 3.0 
 
 1933 
 
 19.3 
 
 248 
 
 2.5 
 
 2181 
 
 21.8 
 
 162 
 
 1.6 
 
 2343 
 
 23.4 
 
 354 
 
 3.5 
 
 765 
 
 7.7 
 
 945 
 
 9.5 
 
 1916 
 
 
 1783 
 
 16.6 
 
 367 
 
 3.4 
 
 2150 
 
 20.1 
 
 305 
 
 2.9 
 
 2455 
 
 22.9 
 
 195 
 
 1.8 
 
 2650 
 
 24.7 
 
 359 
 
 3.4 
 
 815 
 
 7.6 
 
 972 
 
 9.1 
 
 1917 
 
 
 1783 
 
 15.7 
 
 358 
 
 3.2 
 
 2141 
 
 18.8 
 
 305 
 
 2.7 
 
 2446 
 
 21.5 
 
 220 
 
 1.9 
 
 2666 
 
 23.5 
 
 427 
 
 3.8 
 
 910 
 
 8.0 
 
 1120 
 
 9.9 
 
 1918 
 
 
 2259 
 
 14.1 
 
 766 
 
 4.8 
 
 3025 
 
 18.9 
 
 621 
 
 3.9 
 
 3646 
 
 22.7 
 
 365 
 
 2.3 
 
 4011 
 
 25.0 
 
 818 
 
 5.1 
 
 2288 
 
 14.3 
 
 2034 
 
 12.7 
 
 1919 
 
 
 1711 
 
 15.0 
 
 350 
 
 3.1 
 
 2061 
 
 18.0 
 
 418 
 
 3.7 
 
 2479 
 
 21.7 
 
 227 
 
 2.0 
 
 2706 
 
 23.7 
 
 459 
 
 4.0 
 
 1058 
 
 9.3 
 
 1170 
 
 10.2 
 
 1920 
 
 •• 
 
 1960 
 
 17.3 
 
 379 
 
 3.3 
 
 2339 
 
 20.6 
 
 304 
 
 2.7 
 
 2643 
 
 23.3 
 
 202 
 
 1.8 
 
 2845 
 
 25.1 
 
 383 
 
 3.4 
 
 959 
 
 8.4 
 
 1030 
 
 9.1 
 
 
 
 Under 
 
 40 to 49 
 
 Under 
 
 50 to 59 
 
 60 to 69 
 
 70 to 79 
 
 80 to 89 
 
 90 to 99 
 
 100 years 
 
 Unknown 
 
 
 
 40 years* 
 
 years. 
 
 50 years. 
 
 years. 
 
 years. 
 
 years. 
 
 years. 
 
 years. 
 
 and over. 
 
 age. 
 
 
 
 
 00 
 
 
 Vi 
 
 
 CO 
 
 
 CO 
 
 
 CO 
 
 
 CO 
 
 
 CO 
 
 
 CO 
 
 
 Cfi 
 
 
 Gft 
 
 
 
 
 
 
 *- 5 
 
 
 5 
 
 
 -5 
 
 
 *mS 
 
 
 
 
 c*h ^ 
 
 
 tfH 5 
 
 
 
 
 
 
 
 
 O rt 
 
 
 
 
 O 
 
 
 O rt 
 
 
 o cj 
 
 
 O cj 
 
 
 O rt 
 
 
 o Ci 
 
 
 o rt 
 
 
 o rt 
 
 
 
 
 _*_> to 
 
 
 to 
 
 
 
 
 
 
 
 
 M_> 0) 
 
 
 +j <D 
 
 
 o> 
 
 
 -*-> CP 
 
 
 xj to 
 
 
 
 • 
 
 GX 
 
 
 G XI 
 
 • 
 
 C'O 
 
 CO 
 
 £ 'O 
 
 CO 
 
 C *0 
 
 
 C'O 
 
 
 GXJ 
 
 
 C'O 
 
 
 GX 
 
 
 CX 
 
 £ 
 
 
 -M 
 
 <V r-i 
 
 to cj 
 
 XX 
 
 -4-> 
 
 « a) 
 
 XX 
 
 4-> 
 
 to »—H 
 
 to cj 
 
 XX 
 
 -4-> 
 
 to r—< 
 
 o Cj 
 
 X 
 
 <D r-H 
 to cj 
 
 XI 
 
 +-> 
 
 Or-* 
 o Cj 
 
 XX 
 
 +-> 
 
 o Cj 
 
 XX 
 
 -*-> 
 
 <V f-H 
 
 o Cj 
 
 
 CJ ^ 
 
 ^ C3 
 
 XX 
 
 to ^H 
 O d 
 
 d 
 
 
 d 
 
 
 Cj 
 
 
 d 
 
 
 cj 
 
 
 d 
 
 
 cj 
 
 
 cj 
 
 
 cj 
 
 
 d 
 
 ^ 
 
 ci 
 
 ►- -ti 
 
 to 
 
 
 to 
 
 to O 
 
 <u 
 
 
 OP 
 
 to 5 
 
 op 
 
 v 2 
 
 to 
 
 <U O 
 
 o> 
 
 5 
 
 0> 
 
 Q) ® 
 
 0) 
 
 
 0) 
 
 O ° 
 
 to 
 
 o ° 
 
 >< 
 
 
 Q 
 
 Cm^ 
 
 a 
 
 Cm 44 
 
 a 
 
 Cm ^ 
 
 Q 
 
 Cm ~ 
 
 o 
 
 
 D 
 
 Gm*" 
 
 Q 
 
 Cm 
 
 Q 
 
 Dm 
 
 Q 
 
 Cm 4 " 
 
 Q 
 
 Cm ^ 
 
 1814 
 
 
 897 
 
 77.9 
 
 115 
 
 10.0 
 
 1012 
 
 87.9 
 
 49 
 
 4.3 
 
 29 
 
 2.5 
 
 35 
 
 3.0 
 
 25 
 
 2.2 
 
 2 
 
 0.2 
 
 
 
 
 
 1815 
 
 
 1156 
 
 85.7 
 
 58 
 
 4.3 
 
 1214 
 
 90.0 
 
 47 
 
 3.5 
 
 37 
 
 2.7 
 
 37 
 
 2.7 
 
 8 
 
 0.6 
 
 5 
 
 0.4 
 
 i 
 
 o.i 
 
 
 
 1816 
 
 
 1152 
 
 87.5 
 
 53 
 
 4.0 
 
 1205 
 
 91.5 
 
 41 
 
 3.1 
 
 26 
 
 2.0 
 
 37 
 
 2.8 
 
 5 
 
 0.4 
 
 2 
 
 0.2 
 
 l 
 
 0.1 
 
 
 
 1817 
 
 # m 
 
 1108 
 
 83.7 
 
 90 
 
 6.8 
 
 1198 
 
 90.5 
 
 39 
 
 3.0 
 
 24 
 
 1.8 
 
 34 
 
 2.6 
 
 23 
 
 1.7 
 
 4 
 
 0.3 
 
 2 
 
 0.2 
 
 # 
 
 
 1818 
 
 # u 
 
 1419 
 
 82.7 
 
 107 
 
 6.2 
 
 1526 
 
 88.9 
 
 69 
 
 4.0 
 
 43 
 
 2.5 
 
 37 
 
 2.2 
 
 26 
 
 1.5 
 
 13 
 
 0.8 
 
 2 
 
 0.1 
 
 • • • • 
 
 
 1819 
 
 
 1883 
 
 86.3 
 
 117 
 
 5.4 
 
 2000 
 
 91.7 
 
 71 
 
 3.3 
 
 39 
 
 1.8 
 
 35 
 
 1.6 
 
 27 
 
 1.2 
 
 9 
 
 0.4 
 
 1 
 
 0.1 
 
 
 
 1820 
 
 
 1131 
 
 74.1 
 
 133 
 
 8.7 
 
 1264 
 
 82.8 
 
 107 
 
 7.0 
 
 62 
 
 4.1 
 
 35 
 
 2.3 
 
 47 
 
 3.1 
 
 9 
 
 0.6 
 
 3 
 
 0.2 
 
 
 
 1821 
 
 , , 
 
 1360 
 
 71.2 
 
 228 
 
 11.9 
 
 1588 
 
 83.1 
 
 134 
 
 7.0 
 
 83 
 
 4.4 
 
 48 
 
 2.5 
 
 37 
 
 1.9 
 
 15 
 
 0.8 
 
 6 
 
 0.3 
 
 • • • • 
 
 
 1822 
 
 
 1604 
 
 73.0 
 
 239 
 
 10.9 
 
 1843 
 
 83.9 
 
 153 
 
 7.0 
 
 90 
 
 4.1 
 
 63 
 
 2.9 
 
 39 
 
 1.8 
 
 6 
 
 0.3 
 
 4 
 
 0.2 
 
 • • • • 
 
 
 1823 
 
 
 1494 
 
 74.7 
 
 206 
 
 10.3 
 
 1700 
 
 85.0 
 
 131 
 
 6.6 
 
 82 
 
 4.1 
 
 52 
 
 2.6 
 
 28 
 
 1.4 
 
 6 
 
 0.3 
 
 1 
 
 0.1 
 
 • • • • 
 
 
 1824 
 
 
 966 
 
 70.7 
 
 152 
 
 11.1 
 
 1118 
 
 81.9 
 
 79 
 
 5.8 
 
 74 
 
 5.4 
 
 56 
 
 4.1 
 
 29 
 
 2.1 
 
 7 
 
 0.5 
 
 3 
 
 0.2 
 
 • • • • 
 
 
 1825 
 
 
 1041 
 
 71.7 
 
 139 
 
 9.6 
 
 1180 
 
 81.2 
 
 101 
 
 7.0 
 
 80 
 
 5.5 
 
 58 
 
 4.0 
 
 23 
 
 1.6 
 
 9 
 
 0.6 
 
 2 
 
 0.1 
 
 
 .... 
 
 1826 
 
 
 1317 
 
 72.2 
 
 178 
 
 9.8 
 
 1495 
 
 81.9 
 
 131 
 
 7.2 
 
 88 
 
 4.8 
 
 59 
 
 3.2 
 
 41 
 
 2.3 
 
 9 
 
 0.6 
 
 2 
 
 0.1 
 
 
 
 1827 
 
 
 1015 
 
 72.6 
 
 131 
 
 9.4 
 
 1146 
 
 82.0 
 
 110 
 
 7.9 
 
 56 
 
 4.0 
 
 49 
 
 3.5 
 
 28 
 
 2.0 
 
 8 
 
 0.6 
 
 1 
 
 0.1 
 
 
 
 1828 
 
 , # 
 
 1166 
 
 72.3 
 
 155 
 
 9.6 
 
 1321 
 
 82.0 
 
 106 
 
 6.6 
 
 83 
 
 5.2 
 
 51 
 
 3.2 
 
 40 
 
 2.5 
 
 7 
 
 0.4 
 
 4 
 
 0.3 
 
 
 
 1829 
 
 
 1252 
 
 71.8 
 
 176 
 
 10.1 
 
 1428 
 
 81.9 
 
 122 
 
 7.0 
 
 87 
 
 5.0 
 
 65 
 
 3.7 
 
 32 
 
 1.8 
 
 6 
 
 0.3 
 
 3 
 
 0.2 
 
 
 
 1830 
 
 
 1450 
 
 73.5 
 
 214 
 
 10.8 
 
 1664 
 
 84.3 
 
 126 
 
 6.4 
 
 85 
 
 4.3 
 
 57 
 
 2.9 
 
 34 
 
 1.7 
 
 4 
 
 0.2 
 
 4 
 
 0.2 
 
 
 
 1831 
 
 m # 
 
 1669 
 
 76.4 
 
 179 
 
 8.2 
 
 1848 
 
 84.6 
 
 118 
 
 5.4 
 
 103 
 
 4.7 
 
 64 
 
 2.9 
 
 41 
 
 1.9 
 
 6 
 
 0.3 
 
 5 
 
 0.2 
 
 
 
 1832 
 
 
 2388 
 
 69.7 
 
 386 
 
 11.3 
 
 2774 
 
 80.9 
 
 253 
 
 7.4 
 
 194 
 
 5.7 
 
 119 
 
 3.5 
 
 63 
 
 1.8 
 
 16 
 
 0.5 
 
 8 
 
 0.2 
 
 
 
 1833 
 
 
 1824 
 
 , 80.0 
 
 158 
 
 6.9 
 
 1982 
 
 87.0 
 
 107 
 
 4.7 
 
 93 
 
 4.1 
 
 58 
 
 2.5 
 
 30 
 
 1.3 
 
 6 
 
 0.3 
 
 3 
 
 0.1 
 
 
 
 1834 
 
 
 2000 
 
 76.9 
 
 217 
 
 8.4 
 
 2217 
 
 85.3 
 
 144 
 
 5.5 
 
 102 
 
 3.9 
 
 77 
 
 3.0 
 
 44 
 
 1.7 
 
 10 
 
 0.4 
 
 6 
 
 0.2 
 
 
 
 1835 
 
 , # 
 
 i 1368 
 
 72.2 
 
 196 
 
 10.3 
 
 1564 
 
 82.5 
 
 122 
 
 6.4 
 
 81 
 
 4.3 
 
 76 
 
 4.0 
 
 39 
 
 2.1 
 
 8 
 
 0.4 
 
 6 
 
 0.3 
 
 
 
 1836 
 
 
 1589 
 
 72.5 
 
 191 
 
 8.7 
 
 1780 
 
 81.2 
 
 147 
 
 6.7 
 
 124 
 
 5.7 
 
 81 
 
 3.7 
 
 41 
 
 1.9 
 
 11 
 
 0.5 
 
 8 
 
 0.4 
 
 
 
 1837 
 
 
 I 2016 
 
 80.1 
 
 162 
 
 6.4 
 
 2178 
 
 86.5 
 
 103 
 
 4.1 
 
 115 
 
 4.6 
 
 80 
 
 3.2 
 
 35 
 
 1.4 
 
 6 
 
 0.2 
 
 1 
 
 0.4 
 
 
 
 1838 
 
 
 1950 
 
 78.8 
 
 188 
 
 7.6 
 
 2138 
 
 86.4 
 
 124 
 
 5.0 
 
 98 
 
 4.0 
 
 61 
 
 2.5 
 
 44 
 
 1.8 
 
 8 
 
 0.3 
 
 3 
 
 0.1 
 
 
 
 1839 
 
 # # 
 
 1755 
 
 77.7 
 
 148 
 
 6.6 
 
 i 1903 
 
 84.2 
 
 116 
 
 5.1 
 
 97 
 
 4.3 
 
 88 
 
 3.9 
 
 45 
 
 2.0 
 
 9 
 
 0.4 
 
 2 
 
 0.1 
 
 
 
 1840 
 
 # , 
 
 1 1544 
 
 75.5 
 
 166 
 
 8.1 
 
 1710 
 
 83.6 
 
 126 
 
 6.2 
 
 82 
 
 4.0 
 
 76 
 
 3.7 
 
 44 
 
 2.2 
 
 5 
 
 0.2 
 
 2 
 
 0.1 
 
 
 
 1841 
 
 
 1726 
 
 76.8 
 
 165 
 
 7.3 
 
 1891 
 
 84.2 
 
 120 
 
 5.3 
 
 107 
 
 4.8 
 
 73 
 
 3.3 
 
 45 
 
 2.0 
 
 8 
 
 0.4 
 
 3 
 
 0.1 
 
 
 
 1842 
 
 m # 
 
 ! 1954 
 
 78.9 
 
 190 
 
 7.7 
 
 2144 
 
 86.6 
 
 109 
 
 4.4 
 
 93 
 
 3.8 
 
 66 
 
 2.7 
 
 49 
 
 2.0 
 
 10 
 
 0.4 
 
 6 
 
 0.2 
 
 
 
 1843 
 
 
 1778 
 
 76.2 
 
 166 
 
 7.1 
 
 1944 
 
 83.3 
 
 112 
 
 4.8 
 
 132 
 
 5.7 
 
 94 
 
 4.0 
 
 42 
 
 1.8 
 
 9 
 
 0.4 
 
 2 
 
 0.1 
 
 
 
 1844 
 
 # # 
 
 2071 
 
 l 77.7 
 
 222 
 
 8.3 
 
 2293 
 
 86.0 
 
 126 
 
 4.7 
 
 110 
 
 4.1 
 
 72 
 
 2.7 
 
 42 
 
 1.6 
 
 13 
 
 0.5 
 
 9 
 
 0.3 
 
 
 
 1845 
 
 • • 
 
 i 2281 
 
 1 78.8 
 
 228 
 
 7.9 
 
 2509 
 
 86.6 
 
 144 
 
 5.0 
 
 115 
 
 4.0 
 
 71 
 
 2.5 
 
 37 
 
 1.3 
 
 14 
 
 0.5 
 
 6 
 
 0.2 
 
 . . • • 
 
 
 (522) 
 
Table 138.— Percentage, by separate years, of deaths by specified age-periods of total deaths 
 
 from all causes, from 1814 to 1920, inclusive. —Continued. 
 
 Year. 
 
 Under 
 
 40 years. 
 
 40 to 49 
 years. 
 
 Under 
 
 50 years. 
 
 50 to 59 
 years. 
 
 60 to 69 
 years. 
 
 70 to 79 
 years. 
 
 80 to 89 
 yearB. 
 
 90 to 99 
 years. 
 
 100 years 
 and over. 
 
 Unknown 
 
 age. 
 
 Deaths. 
 
 Per cent of 
 total deaths- 
 
 Deaths. 
 
 Per cent of 
 total deaths. 
 
 Deaths. 
 
 Per cent of 
 
 total deaths. 
 
 Deaths. 
 
 Per cent of 
 
 total deaths. 
 
 Deaths. 
 
 Per cent of 
 
 total deaths. 
 
 Deaths. 
 
 Per cent of 
 
 total deaths. 
 
 Deaths. 
 
 Per cent of 
 
 total deaths. 
 
 Deaths. 
 
 Per cent of 
 
 tatal deaths. 
 
 Deaths. 
 
 Per cent of 
 
 total deaths. 
 
 Deaths- 
 
 Per cent of 
 
 total deaths- 
 
 1846 
 
 
 9397 
 
 77.7 
 
 232 
 
 7.8 
 
 2559 
 
 85.5 
 
 135 
 
 4.5 
 
 129 
 
 4 3 
 
 94 
 
 3 1 
 
 59 
 
 2.0 
 
 15 
 
 0.5 
 
 3 
 
 0.1 
 
 1 
 
 1847 
 
 
 2649 
 
 77.6 
 
 259 
 
 7.6 
 
 2908 
 
 85.2 
 
 176 
 
 6.2 
 
 124 
 
 3.6 
 
 133 
 
 3.9 
 
 57 
 
 2.0 
 
 12 
 
 0.4 
 
 4 
 
 0.1 
 
 
 1848 
 
 
 3066 
 
 79.4 
 
 261 
 
 6.8 
 
 3327 
 
 86.2 
 
 174 
 
 4.5 
 
 152 
 
 3.9 
 
 128 
 
 3.3 
 
 57 
 
 1.5 
 
 17 
 
 0.4 
 
 6 
 
 0.2 
 
 
 1849 
 
 
 3188 
 
 76.5 
 
 336 
 
 8.1 
 
 3524 
 
 84.6 
 
 195 
 
 4.7 
 
 207 
 
 5.0 
 
 152 
 
 3.7 
 
 69 
 
 1.4 
 
 21 
 
 0.5 
 
 7 
 
 0 2 
 
 ... 
 
 1850 
 
 
 3345 
 
 79.5 
 
 278 
 
 6.6 
 
 3623 
 
 86.1 
 
 220 
 
 6.2 
 
 157 
 
 3.7 
 
 134 
 
 3.2 
 
 59 
 
 1.4 
 
 13 
 
 0.3 
 
 4 
 
 0.1 
 
 
 1851 
 
 
 3261 
 
 78.2 
 
 315 
 
 7.6 
 
 3576 
 
 85.8 
 
 189 
 
 4.5 
 
 176 
 
 4.2 
 
 166 
 
 4.0 
 
 49 
 
 1.2 
 
 10 
 
 0.2 
 
 3 
 
 0.1 
 
 
 
 1852 
 
 
 3974 
 
 80.0 
 
 339 
 
 6.8 
 
 4313 
 
 86.9 
 
 215 
 
 4.3 
 
 202 
 
 4.1 
 
 144 
 
 2.9 
 
 66 
 
 1.3 
 
 19 
 
 0.4 
 
 6 
 
 0.1 
 
 
 
 1853 
 
 
 3748 
 
 78.0 
 
 357 
 
 7.4 
 
 4105 
 
 85.5 
 
 221 
 
 4.6 
 
 228 
 
 4.8 
 
 146 
 
 3.0 
 
 79 
 
 1.6 
 
 21 
 
 0.4 
 
 3 
 
 0.1 
 
 
 
 1854 
 
 
 4230 
 
 79.2 
 
 386 
 
 7.2 
 
 4616 
 
 86.4 
 
 253 
 
 4.7 
 
 237 
 
 4 4 
 
 143 
 
 2.7 
 
 65 
 
 1.2 
 
 17 
 
 0.3 
 
 12 
 
 0.2 
 
 
 
 1855 
 
 
 3934 
 
 77.5 
 
 356 
 
 7.0 
 
 4290 
 
 84.5 
 
 281 
 
 5.5 
 
 221 
 
 4.4 
 
 169 
 
 3.3 
 
 82 
 
 1.6 
 
 25 
 
 0.5 
 
 7 
 
 0.1 
 
 
 
 1856 
 
 
 4132 
 
 79.0 
 
 359 
 
 6.9 
 
 4491 
 
 85.9 
 
 225 
 
 4.3 
 
 222 
 
 4 3 
 
 183 
 
 3.5 
 
 86 
 
 1.6 
 
 15 
 
 0.3 
 
 7 
 
 0.1 
 
 
 
 1857 
 
 
 4035 
 
 78.8 
 
 358 
 
 7.0 
 
 4393 
 
 85.8 
 
 235 
 
 4.6 
 
 225 
 
 4.4 
 
 163 
 
 3.2 
 
 73 
 
 1.4 
 
 23 
 
 0.5 
 
 8 
 
 0.2 
 
 
 • . , ( 
 
 1858 
 
 
 4280 
 
 79.2 
 
 346 
 
 6.4 
 
 4626 
 
 85.6 
 
 220 
 
 4.1 
 
 261 
 
 4 8 
 
 173 
 
 3.2 
 
 100 
 
 1.9 
 
 22 
 
 0.4 
 
 5 
 
 0.1 
 
 
 
 1859 
 
 
 3675 
 
 78.6 
 
 298 
 
 6.4 
 
 3973 
 
 85.0 
 
 226 
 
 4.8 
 
 220 
 
 4.7 
 
 153 
 
 3.3 
 
 73 
 
 1.6 
 
 23 
 
 0.5 
 
 6 
 
 0.1 
 
 
 
 1860 
 
 
 3711 
 
 76.3 
 
 323 
 
 6.6 
 
 4034 
 
 82.9 
 
 243 
 
 6.0 
 
 260 
 
 5 3 
 
 210 
 
 4.3 
 
 106 
 
 2.2 
 
 9 
 
 0.2 
 
 4 
 
 0.1 
 
 
 
 1861 
 
 
 3621 
 
 75.6 
 
 366 
 
 7.6 
 
 3987 
 
 83.2 
 
 251 
 
 5.2 
 
 244 
 
 5 1 
 
 192 
 
 4.0 
 
 95 
 
 2.0 
 
 14 
 
 0.3 
 
 7 
 
 0.2 
 
 
 
 1862 
 
 
 3969 
 
 76.7 
 
 373 
 
 7.2 
 
 4342 
 
 83.9 
 
 264 
 
 5.1 
 
 252 
 
 4 9 
 
 185 
 
 3.6 
 
 92 
 
 1.8 
 
 29 
 
 0.6 
 
 9 
 
 0.2 
 
 
 • 
 
 1863 
 
 
 4252 
 
 76.6 
 
 410 
 
 7.4 
 
 4662 
 
 84.0 
 
 268 
 
 4.8 
 
 286 
 
 5 2 
 
 202 
 
 3.6 
 
 107 
 
 1.9 
 
 17 
 
 0.3 
 
 9 
 
 0.2 
 
 
 
 1864 
 
 
 4399 
 
 77.5 
 
 401 
 
 7.1 
 
 4800 
 
 84.5 
 
 282 
 
 5.0 
 
 263 
 
 4 6 
 
 204 
 
 3.6 
 
 101 
 
 1.8 
 
 22 
 
 0.4 
 
 6 
 
 0.1 
 
 
 
 1865 
 
 
 3529 
 
 75.2 
 
 327 
 
 7.0 
 
 3856 
 
 82.1 
 
 275 
 
 5.9 
 
 267 
 
 5.7 
 
 179 
 
 3.8 
 
 85 
 
 1.8 
 
 27 
 
 0.6 
 
 6 
 
 0.1 
 
 
 
 1866 
 
 
 4153 
 
 73.9 
 
 429 
 
 7.6 
 
 4582 
 
 81.5 
 
 356 
 
 6.3 
 
 321 
 
 5.7 
 
 218 
 
 3.9 
 
 123 
 
 2.2 
 
 21 
 
 0.4 
 
 2 
 
 .04 
 
 
 
 1867 
 
 
 3891 
 
 73.6 
 
 455 
 
 8.6 
 
 4346 
 
 82.3 
 
 333 
 
 6.3 
 
 283 
 
 5.4 
 
 206 
 
 3.9 
 
 94 
 
 1.8 
 
 21 
 
 0.4 
 
 1 
 
 .02 
 
 
 
 1868 
 
 
 4704 
 
 76.1 
 
 454 
 
 7.3 
 
 5158 
 
 83.5 
 
 386 
 
 6.3 
 
 299 
 
 4.8 
 
 203 
 
 3.3 
 
 112 
 
 1.8 
 
 19 
 
 0.3 
 
 1 
 
 .02 
 
 
 
 1869 
 
 
 4943 
 
 76.1 
 
 482 
 
 7.4 
 
 5425 
 
 83.5 
 
 367 
 
 5.7 
 
 362 
 
 5.6 
 
 209 
 
 3.2 
 
 110 
 
 1.7 
 
 19 
 
 0.3 
 
 5 
 
 0 1 
 
 
 
 1870 
 
 
 5472 
 
 75.3 
 
 500 
 
 6.9 
 
 5972 
 
 82.2 
 
 443 
 
 6.1 
 
 385 
 
 5.3 
 
 278 
 
 3.8 
 
 154 
 
 2.1 
 
 26 
 
 0.4 
 
 4 
 
 0.1 
 
 
 
 1871 
 
 
 5498 
 
 76.0 
 
 493 
 
 6.9 
 
 5921 
 
 82.9 
 
 436 
 
 6.1 
 
 330 
 
 4 6 
 
 288 
 
 4.0 
 
 130 
 
 1.8 
 
 31 
 
 0.4 
 
 5 
 
 0 1 
 
 
 
 1872 
 
 
 6817 
 
 77.0 
 
 614 
 
 6.9 
 
 7431 
 
 83.9 
 
 473 
 
 5.3 
 
 422 
 
 4.8 
 
 310 
 
 3.5 
 
 181 
 
 2.0 
 
 28 
 
 0.3 
 
 7 
 
 0 1 
 
 
 
 1873 
 
 
 5553 
 
 73.2 
 
 548 
 
 7.2 
 
 6101 
 
 80.4 
 
 470 
 
 6.2 
 
 426 
 
 5 6 
 
 371 
 
 4.9 
 
 164 
 
 2.2 
 
 48 
 
 0.6 
 
 9 
 
 0.1 
 
 
 
 1874 
 
 
 5477 
 
 74.2 
 
 472 
 
 6.4 
 
 5949 
 
 80.6 
 
 447 
 
 6.1 
 
 438 
 
 5.9 
 
 359 
 
 4.9 
 
 153 
 
 2.1 
 
 28 
 
 0.4 
 
 5 
 
 0.1 
 
 
 
 1875 
 
 
 5349 
 
 73.7 
 
 464 
 
 6.4 
 
 5813 
 
 80.1 
 
 551 
 
 7.6 
 
 558 
 
 7.7 
 
 348 
 
 4.8 
 
 144 
 
 2.0 
 
 39 
 
 0.5 
 
 4 
 
 0.1 
 
 
 
 1876 
 
 
 5626 
 
 75.0 
 
 482 
 
 6.4 
 
 6108 
 
 81.5 
 
 436 
 
 6.8 
 
 419 
 
 5.6 
 
 370 
 
 4.9 
 
 137 
 
 1.8 
 
 21 
 
 0.3 
 
 7 
 
 0 1 
 
 
 
 1877 
 
 
 6117 
 
 77.3 
 
 436 
 
 5.5 
 
 6553 
 
 82.9 
 
 436 
 
 5.5 
 
 405 
 
 5.1 
 
 366 
 
 4.6 
 
 131 
 
 1.7 
 
 15 
 
 0.2 
 
 4 
 
 0.1 
 
 
 
 1878 
 
 
 4758 
 
 70.7 
 
 455 
 
 6.8 
 
 5213 
 
 77.4 
 
 452 
 
 6.7 
 
 485 
 
 7.2 
 
 392 
 
 5.8 
 
 148 
 
 2.2 
 
 33 
 
 0.5 
 
 10 
 
 0.2 
 
 
 
 1879 
 
 
 5493 
 
 72.1 
 
 489 
 
 6.4 
 
 5982 
 
 78.5 
 
 443 
 
 5.8 
 
 534 
 
 7.0 
 
 435 
 
 5.7 
 
 175 
 
 2.3 
 
 43 
 
 0.6 
 
 6 
 
 0 1 
 
 
 
 1880 
 
 
 5801 
 
 72.1 
 
 529 
 
 6.6 
 
 6330 
 
 78.7 
 
 529 
 
 6.6 
 
 514 
 
 6.4 
 
 426 
 
 5.3 
 
 204 
 
 2.5 
 
 31 
 
 0.4 
 
 9 
 
 0.1 
 
 
 
 1881 
 
 
 6418 
 
 72.8 
 
 507 
 
 5.8 
 
 6925 
 
 78.6 
 
 589 
 
 6.7 
 
 596 
 
 6.8 
 
 482 
 
 5.5 
 
 184 
 
 2.1 
 
 36 
 
 0.4 
 
 4 
 
 0.1 
 
 
 
 1882 
 
 
 6407 
 
 71.8 
 
 561 
 
 6.3 
 
 6968 
 
 78.1 
 
 561 
 
 6.3 
 
 615 
 
 6.9 
 
 527 
 
 5.9 
 
 214 
 
 2.4 
 
 34 
 
 0.4 
 
 6 
 
 0.1 
 
 
 
 1883 
 
 
 6895 
 
 74.5 
 
 574 
 
 6.1 
 
 7469 
 
 80.6 
 
 575 
 
 6.1 
 
 604 
 
 6 4 
 
 478 
 
 5.1 
 
 222 
 
 2.4 
 
 31 
 
 0.3 
 
 1 
 
 01 
 
 
 
 1884 
 
 
 6880 
 
 70.9 
 
 547 
 
 6.6 
 
 6427 
 
 77.5 
 
 505 
 
 6.1 
 
 584 
 
 7.0 
 
 517 
 
 6.2 
 
 229 
 
 2.8 
 
 27 
 
 0.3 
 
 4 
 
 0 1 
 
 
 
 1885 
 
 
 5478 
 
 67.2 
 
 566 
 
 6.9 
 
 6044 
 
 74.1 
 
 626 
 
 7.7 
 
 662 
 
 8.1 
 
 527 
 
 6.5 
 
 260 
 
 3.2 
 
 28 
 
 0.3 
 
 6 
 
 0 1 
 
 
 
 1886 
 
 
 5768 
 
 69.2 
 
 568 
 
 6.8 
 
 6336 
 
 76.0 
 
 551 
 
 6.6 
 
 720 
 
 8.6 
 
 482 
 
 5.8 
 
 220 
 
 2.6 
 
 27 
 
 0.3 
 
 3 
 
 04 
 
 
 
 1887 
 
 
 5564 
 
 66.5 
 
 644 
 
 7.7 
 
 6208 
 
 74.2 
 
 605 
 
 7.2 
 
 717 
 
 8.6 
 
 552 
 
 6.6 
 
 251 
 
 3.0 
 
 37 
 
 0.4 
 
 2 
 
 02 
 
 
 
 1888 
 
 
 6068 
 
 67.9 
 
 645 
 
 7.2 
 
 6713 
 
 75.1 
 
 644 
 
 7.2 
 
 768 
 
 8.6 
 
 510 
 
 5.7 
 
 262 
 
 2.9 
 
 31 
 
 0.4 
 
 8 
 
 0 1 
 
 
 
 1889 
 
 
 5744 
 
 66.0 
 
 661 
 
 7.6 
 
 6405 
 
 73.6 
 
 701 
 
 8.0 
 
 826 
 
 9.5 
 
 501 
 
 5.8 
 
 234 
 
 2.7 
 
 33 
 
 0.4 
 
 3 
 
 03 
 
 
 
 1890 
 
 
 6714 
 
 65.9 
 
 784 
 
 7.7 
 
 7498 
 
 73.5 
 
 804 
 
 7.9 
 
 1085 
 
 10.6 
 
 498 
 
 4.9 
 
 264 
 
 2.6 
 
 41 
 
 0.4 
 
 8 
 
 0 1 
 
 
 
 1891 
 
 
 6218 
 
 62.0 
 
 789 
 
 7.ii 
 
 7037 
 
 69.9 
 
 829 
 
 8.2 
 
 928 
 
 9.2 
 
 806 
 
 8.0 
 
 402 
 
 4.0 
 
 67 
 
 0.7 
 
 4 
 
 .04 
 
 
 • • • • 
 
 1892 
 
 
 7006 
 
 66.2 
 
 748 
 
 7.1 
 
 7754 
 
 73.3 
 
 798 
 
 7.5 
 
 873 
 
 8.3 
 
 728 
 
 6.9 
 
 371 
 
 3.5 
 
 53 
 
 0.5 
 
 5 
 
 0 1 
 
 
 
 1893 
 
 
 5932 
 
 62.1 
 
 816 
 
 8.5 
 
 6748 
 
 70.6 
 
 780 
 
 8.2 
 
 866 
 
 9.1 
 
 742 
 
 7.8 
 
 366 
 
 3.8 
 
 44 
 
 0.5 
 
 8 
 
 0 1 
 
 
 
 1894 
 
 
 6033 
 
 63.6 
 
 735 
 
 7.8 
 
 6768 
 
 71.4 
 
 801 
 
 8.4 
 
 832 
 
 8.8 
 
 701 
 
 7.4 
 
 322 
 
 3.4 
 
 59 
 
 0.6 
 
 3 
 
 03 
 
 
 
 1895 
 
 
 6411 
 
 62.2 
 
 877 
 
 8.5 
 
 7288 
 
 70.7 
 
 849 
 
 8.2 
 
 924 
 
 9.0 
 
 798 
 
 7.8 
 
 379 
 
 3.7 
 
 57 
 
 0.6 
 
 6 
 
 0 1 
 
 
 
 1896 
 
 
 6115 
 
 61.7 
 
 804 
 
 8.1 
 
 6919 
 
 69.8 
 
 881 
 
 8.9 
 
 958 
 
 9.7 
 
 791 
 
 8.0 
 
 323 
 
 3.3 
 
 42 
 
 0.4 
 
 5 
 
 0 1 
 
 
 
 1897 
 
 
 5797 
 
 62.1 
 
 791 
 
 8.5 
 
 6588 
 
 70.6 
 
 814 
 
 8.7 
 
 831 
 
 8.9 
 
 737 
 
 8.0 
 
 313 
 
 3.4 
 
 41 
 
 0.4 
 
 5 
 
 0 1 
 
 
 
 1898 
 
 
 6443 
 
 62.0 
 
 809 
 
 7.8 
 
 7252 
 
 69.8 
 
 917 
 
 8.8 
 
 881 
 
 8.5 
 
 834 
 
 8.0 
 
 396 
 
 3.8 
 
 57 
 
 0.6 
 
 0 
 
 .02 
 
 46 
 
 0.4 
 
 1899 
 
 
 5921 
 
 58.3 
 
 884 
 
 8.7 
 
 6805 
 
 67.0 
 
 963 
 
 9.5 
 
 1037 
 
 10.2 
 
 895 
 
 8.8 
 
 377 
 
 3.7 
 
 68 
 
 0.7 
 
 2 
 
 .02 
 
 5 
 
 0.1 
 
 1900 
 
 
 6366 
 
 59.5 
 
 952 
 
 8.9 
 
 7318 
 
 68.4 
 
 959 
 
 9.0 
 
 1084 
 
 10.1 
 
 860 
 
 8.0 
 
 407 
 
 3.8 
 
 70 
 
 0.7 
 
 2 
 
 02 
 
 
 
 1901 
 
 
 5959 
 
 56.9 
 
 1029 
 
 9.8 
 
 6988 
 
 66.7 
 
 984 
 
 9.4 
 
 1109 
 
 10.6 
 
 929 
 
 8.9 
 
 405 
 
 3.9 
 
 57 
 
 0.5 
 
 7 
 
 0.1 
 
 
 • • • • • 
 
 1902 
 
 
 5829 
 
 56.9 
 
 982 
 
 9.6 
 
 6811 
 
 66.4 
 
 1000 
 
 9.8 
 
 1127 
 
 11.0 
 
 875 
 
 8.5 
 
 379 
 
 3.7 
 
 56 
 
 0.6 
 
 5 
 
 0.1 
 
 
 • • • • • 
 
 1903 
 
 
 5624 
 
 55.5 
 
 976 
 
 9.6 
 
 6600 
 
 65.1 
 
 1020 
 
 10.1 
 
 1079 
 
 10.6 
 
 947 
 
 9.3 
 
 416 
 
 4.1 
 
 58 
 
 0.6 
 
 17 
 
 0.2 
 
 4 
 
 .04 
 
 1904 
 
 
 5873 
 
 54.3 
 
 1090 
 
 10.1 
 
 6963 
 
 64.4 
 
 1119 
 
 10.3 
 
 1203 
 
 11.1 
 
 1034 
 
 9.6 
 
 440 
 
 4.1 
 
 52 
 
 0.5 
 
 5 
 
 0.1 
 
 2 
 
 .02 
 
 1905 
 
 
 6020 
 
 56.3 
 
 1042 
 
 9.7 
 
 7062 
 
 66 0 
 
 1056 
 
 9.9 
 
 1176 
 
 11.0 
 
 918 
 
 8.6 
 
 418 
 
 3.9 
 
 53 
 
 0.5 
 
 9 
 
 0.1 
 
 3 
 
 .03 
 
 1906 
 
 
 5947 
 
 55.3 
 
 1164 
 
 10.8 
 
 7111 
 
 66.1 
 
 1104 
 
 10.3 
 
 1085 
 
 10.1 
 
 967 
 
 9.0 
 
 421 
 
 3.9 
 
 54 
 
 0.5 
 
 5 
 
 0.1 
 
 6 
 
 0.1 
 
 1907 
 
 
 6085 
 
 54.4 
 
 1130 
 
 10.1 
 
 7215 
 
 64.5 
 
 1145 
 
 10.2 
 
 1275 
 
 11.4 
 
 993 
 
 8.9 
 
 494 
 
 4.4 
 
 61 
 
 0.6 
 
 4 
 
 .04 
 
 3 
 
 .03 
 
 1908 
 
 
 5500 
 
 52.7 
 
 1055 
 
 10.1 
 
 6555 
 
 62.8 
 
 1127 
 
 10.8 
 
 1215 
 
 11.6 
 
 994 
 
 9.5 
 
 474 
 
 4.5 
 
 65 
 
 0.6 
 
 3 
 
 .03 
 
 2 
 
 .02 
 
 1909 
 
 
 5534 
 
 53.3 
 
 1067 
 
 10.3 
 
 6601 
 
 63.6 
 
 1108 
 
 10.7 
 
 1192 
 
 11.5 
 
 982 
 
 9.5 
 
 433 
 
 4.2 
 
 53 
 
 0.5 
 
 6 
 
 0.1 
 
 1 
 
 .01 
 
 1910 
 
 
 5423 
 
 50.4 
 
 1094 
 
 10.2 
 
 6517 
 
 60.6 
 
 1256 
 
 11.7 
 
 1352 
 
 12.6 
 
 1067 
 
 9.9 
 
 471 
 
 4.4 
 
 81 
 
 0 8 
 
 9 
 
 0 1 
 
 
 
 1911 
 
 
 5134 
 
 49 3 
 
 1067 
 
 10.3 
 
 6201 
 
 59.6 
 
 1276 
 
 12.3 
 
 1249 
 
 12.0 
 
 1087 
 
 10.5 
 
 512 
 
 4.9 
 
 73 
 
 0 7 
 
 6 
 
 0 1 
 
 
 
 1912 
 
 
 5117 
 
 49.0 
 
 1106 
 
 10.6 
 
 6223 
 
 59.6 
 
 1214 
 
 11.6 
 
 1351 
 
 12.9 
 
 1073 
 
 10.3 
 
 492 
 
 4.7 
 
 82 
 
 0.8 
 
 6 
 
 0.1 
 
 1 
 
 .01 
 
 1913 
 
 
 5038 
 
 49.6 
 
 1119 
 
 11.0 
 
 6157 
 
 60.6 
 
 1194 
 
 11.7 
 
 1221 
 
 12.0 
 
 1037 
 
 10.2 
 
 484 
 
 4.8 
 
 72 
 
 0.7 
 
 3 
 
 .03 
 
 • • • • 
 
 • • • • • 
 
 1914 
 
 
 4954 
 
 47.0 
 
 1178 
 
 11.2 
 
 6132 
 
 58.1 
 
 1331 
 
 12.6 
 
 1379 
 
 13.1 
 
 1148 
 
 10.9 
 
 493 
 
 4.7 
 
 66 
 
 0.6 
 
 2 
 
 .02 
 
 
 
 1915 
 
 
 4407 
 
 44.1 
 
 1152 
 
 11.5 
 
 5559 
 
 55 6 
 
 1414 
 
 14.1 
 
 1388 
 
 13.9 
 
 1114 
 
 11.1 
 
 460 
 
 4.6 
 
 62 
 
 0.6 
 
 5 
 
 0.1 
 
 
 
 1916 
 
 
 4796 
 
 44.7 
 
 1276 
 
 11.9 
 
 6072 
 
 56.6 
 
 1426 
 
 13.3 
 
 1437 
 
 13.4 
 
 1212 
 
 11.3 
 
 492 
 
 4.6 
 
 79 
 
 0.7 
 
 1 
 
 .01 
 
 
 
 1917 
 
 
 5123 
 
 45.1 
 
 1301 
 
 11.5 
 
 6424 
 
 56.5 
 
 1486 
 
 13.1 
 
 1585 
 
 14.0 
 
 1264 
 
 11.1 
 
 532 
 
 4.7 
 
 66 
 
 0.6 
 
 7 
 
 0.1 
 
 
 
 1918 
 
 
 9151 
 
 57.1 
 
 1562 
 
 9.7 
 
 9714 
 
 66.8 
 
 1715 
 
 10.7 
 
 1620 
 
 10.1 
 
 1353 
 
 8.4 
 
 546 
 
 3.4 
 
 79 
 
 0.5 
 
 6 
 
 .04 
 
 
 
 1919 
 
 
 5393 
 
 47.2 
 
 1353 
 
 11.8 
 
 6746 
 
 59.0 
 
 1412 
 
 12.4 
 
 1449 
 
 12.7 
 
 1268 
 
 11.1 
 
 495 
 
 4.3 
 
 61 
 
 0.5 
 
 3 
 
 .03 
 
 
 
 1920 
 
 • • 
 
 5217 
 
 45.9 
 
 1174 
 
 10.3 
 
 6391 
 
 56.3 
 
 1448 
 
 12 8 
 
 1569 
 
 13.8 
 
 1325 
 
 11.7 
 
 539 
 
 4.8 
 
 81 
 
 0.7 
 
 3 
 
 .03 
 
 
 
 34 
 
 (523) 
 
Table 139 .—Average 'percentage by 5- and 10-year periods, of deaths by specified age 
 periods of total deaths from all causes from 1814 to 1920, inclusive. 
 
 Period. 
 
 Under 
 
 1 j'ear. 
 
 Between 1 
 and 2 years. 
 
 Under 
 
 2> years. 
 
 2 to 4 
 years. 
 
 Under 
 
 5 years. 
 
 5 to 9 
 years- 
 
 By 5-year 
 
 periods. 
 
 By 10-year 
 
 periods. 
 
 By 5-year 
 
 periods* 
 
 By 10-year 
 
 periods* 
 
 1 
 
 By 5-year 
 
 periods. 
 
 ---I 
 
 By 10-year 
 
 periods. 
 
 | 
 
 By 5-year 
 
 periods. 
 
 By 10-year 
 
 periods. 
 
 By 5-year 
 
 periods. 
 
 By 10-year 
 
 periods. 
 
 By 5-year 
 
 periods. 
 
 By 10-year 
 
 periods. 
 
 1814-1815 . 
 
 27 
 
 
 8 
 
 • • • • 
 
 35 
 
 • • • • 
 
 6 
 
 * • » • 
 
 42 
 
 
 4 
 
 
 1816-1820 . 
 
 29 
 
 29 
 
 9 
 
 9 
 
 39 
 
 38 
 
 5 
 
 5 
 
 44 
 
 43 
 
 4 
 
 4 
 
 1821-1825 . 
 
 19 
 
 • • • • 
 
 8 
 
 • • • • 
 
 27 
 
 >• • • • 
 
 8 
 
 • • • • 
 
 34 
 
 • • • • 
 
 4 
 
 • • • • 
 
 1826-1830 . 
 
 24 
 
 22 
 
 8 
 
 8 
 
 32 
 
 29 
 
 9 
 
 8 
 
 41 
 
 38 
 
 4 
 
 4 
 
 1831-1835 . 
 
 24 
 
 • • • • 
 
 8 
 
 • • • • 
 
 32 
 
 • • • • 
 
 10 
 
 • • • • 
 
 42 
 
 • • • • 
 
 4 
 
 • • . . 
 
 1836-1840 . 
 
 26 
 
 25 
 
 10 
 
 9 
 
 36 
 
 34 
 
 11 
 
 10 
 
 47 
 
 44 
 
 5 
 
 5 
 
 1841-1845 . 
 
 27 
 
 • • • • 
 
 10 
 
 • • • • 
 
 37 
 
 • • • • 
 
 10 
 
 • • • • 
 
 48 
 
 • • • • 
 
 5 
 
 • • • • 
 
 1846-1850 . 
 
 25 
 
 26 
 
 12 
 
 11 
 
 37 
 
 37 
 
 11 
 
 11 
 
 48 
 
 48 
 
 5 
 
 5 
 
 1851-1855 . 
 
 24 
 
 • • • • 
 
 12 
 
 • • • • 
 
 37 
 
 • • • • 
 
 12 
 
 • • • • 
 
 49 
 
 • • • • 
 
 6 
 
 • • • • 
 
 1856-1860 . 
 
 26 
 
 25 
 
 14 
 
 13 
 
 39 
 
 38 
 
 12 
 
 12 
 
 51 
 
 50 
 
 6 
 
 6 
 
 1861-1865 . 
 
 23 
 
 » • • • 
 
 11 
 
 • • • • 
 
 33 
 
 • • • • 
 
 14 
 
 • • • • 
 
 47 
 
 • • • • 
 
 7 
 
 • • • • 
 
 1866-1870 . 
 
 26 
 
 24 
 
 12 
 
 11 
 
 37 
 
 35 
 
 11 
 
 12 
 
 48 
 
 48 
 
 5 
 
 6 
 
 1871-1875 . 
 
 26 
 
 • • • • 
 
 11 
 
 • • • • 
 
 38 
 
 • • • • 
 
 9 
 
 • • • • 
 
 47 
 
 • • • • 
 
 5 
 
 • • • • 
 
 1876-1880 . 
 
 28 
 
 27 
 
 11 
 
 11 
 
 40 
 
 39 
 
 7 
 
 8 
 
 46 
 
 47 
 
 6 
 
 6 
 
 1881-1885 . 
 
 26 
 
 » • • • 
 
 9 
 
 • • • • 
 
 36 
 
 • • • • 
 
 7 
 
 • • • « 
 
 43 
 
 • • • • 
 
 7 
 
 • • • • 
 
 1886-1890 . 
 
 29 
 
 28 
 
 8 
 
 9 
 
 37 
 
 36 
 
 5 
 
 6 
 
 42 
 
 42 
 
 4 
 
 5 
 
 1891-1895 . 
 
 27 
 
 • • • • 
 
 7 
 
 • • • • 
 
 34 
 
 • • • • 
 
 5 
 
 • • • • 
 
 39 
 
 • • • • 
 
 3 
 
 • • • • 
 
 1896-1900 . 
 
 25 
 
 '26 
 
 5 
 
 6 
 
 31 
 
 32 
 
 5 
 
 5 
 
 36 
 
 38 
 
 3 
 
 3 
 
 1901-1905 . 
 
 23 
 
 • • • • 
 
 4 
 
 • • • • 
 
 27 
 
 • • • • 
 
 4 
 
 • • • • 
 
 31 
 
 • • • • 
 
 2 
 
 • • • • 
 
 1906-1910 . 
 
 21 
 
 22 
 
 4 
 
 4 
 
 26 
 
 26 
 
 3 
 
 4 
 
 29 
 
 30 
 
 2 
 
 2 
 
 1911-1915 . 
 
 19 
 
 • • • • 
 
 4 
 
 • • • • 
 
 22 
 
 • • • • 
 
 3 
 
 • • • • 
 
 25 
 
 • • • • 
 
 2 
 
 • • • • 
 
 1916-1920 . 
 
 16 
 
 17 
 
 4 
 
 4 
 
 19 
 
 21 
 
 3 
 
 3 
 
 22 
 
 24 
 
 2 
 
 2 
 
 * 
 
 —126 
 
 
 
 
 47 
 
 
 
 — 
 
 68 
 
 
 43 
 
 Period. 
 
 Under 
 
 10 years. 
 
 10 to 19 
 years. 
 
 Under 
 
 20 years. 
 
 20 to 29 
 years. 
 
 Under 
 
 30 years. 
 
 30 to 39 
 years. 
 
 By 5-year 
 periods- 
 
 By 10-year 
 periods- 
 
 By 5-year 
 periods. 
 
 By 10-year 
 periods. 
 
 By 5-year 
 periods. 
 
 By 10-year 
 periods. 
 
 By 5-year 
 periods. 
 
 By 10-year 
 periods. 
 
 By 5-year 
 periods. 
 
 By 10-year 
 periods. 
 
 By 5-year 
 periods. 
 
 By 10-year 
 periods. 
 
 1814-1815 . 
 
 46 
 
 • • • • 
 
 10 
 
 • • • • 
 
 56 
 
 • • • • 
 
 14 
 
 * • • • 
 
 71 
 
 • • • • 
 
 11 
 
 • • • • 
 
 1816-1820 . 
 
 48 
 
 47 
 
 10 
 
 10 
 
 58 
 
 58 
 
 14 
 
 14 
 
 72 
 
 72 
 
 11 
 
 11 
 
 1821-1825 . 
 
 39 
 
 • • • • 
 
 8 
 
 • • • • 
 
 47 
 
 • • • • ' 
 
 12 
 
 • • • • 
 
 59 
 
 • • • • 
 
 13 
 
 • • • • 
 
 1826-1830 . 
 
 45 
 
 42 
 
 6 
 
 7 
 
 52 
 
 49 
 
 10 
 
 11 
 
 61 
 
 60 
 
 11 
 
 12 
 
 1831-1835 . 
 
 46 
 
 • • • • 
 
 7 
 
 • • • • 
 
 53 
 
 • • • • 
 
 11 
 
 • • • • 
 
 63 
 
 • • • • 
 
 12 
 
 • • • • 
 
 1836-1840 . 
 
 51 
 
 49 
 
 6 
 
 6 
 
 57 
 
 55 
 
 9 
 
 10 
 
 66 
 
 65 
 
 10 
 
 11 
 
 1841-1845 . 
 
 53 
 
 • • • • 
 
 6 
 
 • • • • 
 
 58 
 
 • • • • 
 
 9 
 
 • • • • 
 
 68 
 
 • • • • 
 
 10 
 
 • • • • 
 
 1846-1850 . 
 
 53 
 
 53 
 
 6 
 
 6 
 
 59 
 
 59 
 
 9 
 
 9 
 
 68 
 
 68 
 
 10 
 
 10 
 
 1851-1855 . 
 
 54 
 
 • • • • 
 
 5 
 
 • • • • 
 
 60 
 
 • • • • 
 
 10 
 
 » • • • 
 
 69 
 
 • • • • 
 
 9 
 
 • • • • 
 
 1856-1860 . 
 
 57 
 
 56 
 
 5 
 
 5 
 
 62 
 
 61 
 
 8 
 
 9 
 
 70 
 
 70 
 
 8 
 
 9 
 
 1861-1865 . 
 
 54 
 
 • « * • 
 
 5 
 
 • • • • 
 
 59 
 
 • • • • 
 
 9 
 
 » ♦ • • 
 
 68 
 
 • • • • 
 
 8 
 
 • • • • 
 
 1866-1870 . 
 
 53 
 
 53 
 
 5 
 
 5 
 
 58 
 
 58 
 
 9 
 
 9 
 
 67 
 
 67 
 
 8 
 
 8 
 
 1871-1875 . 
 
 52 
 
 • • • • 
 
 6 
 
 • • • • 
 
 58 
 
 • • • • 
 
 9 
 
 • • • • 
 
 67 
 
 • • • • 
 
 8 
 
 • • • • 
 
 1876-1880 . 
 
 53 
 
 52 
 
 5 
 
 6 
 
 58 
 
 58 
 
 8 
 
 8 
 
 66 
 
 67 
 
 7 
 
 8 
 
 1881-1885 . 
 
 50 
 
 • • • • 
 
 5 
 
 • • • • 
 
 55 
 
 • • • • 
 
 9 
 
 • • • • 
 
 64 
 
 • • • • 
 
 8 
 
 • • • • 
 
 1886-1890 . 
 
 46 
 
 48 
 
 5 
 
 5 
 
 50 
 
 52 
 
 9 
 
 9 
 
 59 
 
 61 
 
 8 
 
 8 
 
 1891-1895 . 
 
 43 
 
 • • • • 
 
 5 
 
 • • • • 
 
 47 
 
 • • • • 
 
 8 
 
 • • • « 
 
 55 
 
 • • • • 
 
 8 
 
 • • • • 
 
 1896-1900 . 
 
 39 
 
 41 
 
 5 
 
 5 
 
 44 
 
 46 
 
 8 
 
 8 
 
 52 
 
 54 
 
 9 
 
 8 
 
 1901-1905 . 
 
 34 
 
 • • • • 
 
 4 
 
 • • • • 
 
 38 
 
 • • • • 
 
 9 
 
 % • • • 
 
 47 
 
 • • • • 
 
 9 
 
 • • • • 
 
 1906-1910 . 
 
 31 
 
 32 
 
 4 
 
 4 
 
 35 
 
 37 
 
 9 
 
 9 
 
 44 
 
 45 
 
 9 
 
 9 
 
 1911-1915 . 
 
 27 
 
 • • • • 
 
 3 
 
 • • * • 
 
 30 
 
 • • • • 
 
 8 
 
 • • • • 
 
 39 
 
 .« • • • 
 
 9 
 
 • • • • 
 
 1916-1920 . 
 
 24 
 
 26 
 
 4 
 
 4 
 
 28 
 
 29 
 
 10 
 
 9 
 
 38 
 
 38 
 
 10 
 
 10 
 
 * 
 
 -61 
 
 -64 
 
 -27 
 
 • 
 
 
 -18 
 
 • • 
 
 • • 
 
 * Percentage of changes in age distribution of deaths from all causes dependent upon per¬ 
 centage of changes in age distribution of population from 1850 to 1920. 
 
 Plus signs denote percentage of increase and minus signs denote percentage of decrease. 
 
 (524) 
 
Table 139 .—Average 'percentage by 5- and 10-year periods, of deaths by specified age 
 periods of total deaths from all causes from 1814 to 1920, inclusive. —Continued. 
 
 Period. 
 
 Under 
 
 40 years. 
 
 40 to 40 
 years. 
 
 Under 
 
 50 years. 
 
 60 to 59 
 years. 
 
 Under 
 
 60 years. 
 
 60 to 69 
 years. 
 
 By 5-year 
 
 periods. 
 
 By 10-year 
 
 periods. 
 
 By 5-year 
 
 periods. 
 
 By 10-year 
 
 periods- 
 
 By 5-year 
 
 periods. 
 
 By 10-year 
 
 periods. 
 
 By 5-year 
 
 periods. 
 
 By 10-year 
 
 periods. 
 
 By 5-year 
 
 periods. 
 
 By 10-year 
 
 periods. 
 
 By 5-year 
 
 periods- 
 
 By 10-year 
 
 periods. 
 
 1814-1815 . 
 
 82 
 
 
 7 
 
 • • • • 
 
 89 
 
 • • • • 
 
 4 
 
 • • • • 
 
 93 
 
 • • • • 
 
 3 
 
 • • • • 
 
 1816-1820 . 
 
 83 
 
 83 
 
 6 
 
 6 
 
 89 
 
 89 
 
 4 
 
 4 
 
 93 
 
 93 
 
 2 
 
 2 
 
 1821-1825 . 
 
 72 
 
 « • • • 
 
 11 
 
 • • • • 
 
 83 
 
 • • • • 
 
 7 
 
 • • • • 
 
 90 
 
 • • • • 
 
 5 
 
 • • • • 
 
 1826-1830 . 
 
 72 
 
 72 
 
 10 
 
 10 
 
 82 
 
 83 
 
 7 
 
 7 
 
 89 
 
 90 
 
 5 
 
 5 
 
 1831-1835 . 
 
 75 
 
 • • • • 
 
 9 
 
 • • • • 
 
 84 
 
 • • • • 
 
 6 
 
 • • • • 
 
 90 
 
 • • • • 
 
 5 
 
 • • • • 
 
 1836-1840 . 
 
 77 
 
 76 
 
 7 
 
 8 
 
 84 
 
 84 
 
 5 
 
 6 
 
 90 
 
 90 
 
 5 
 
 5 
 
 1841-1845 . 
 
 78 
 
 • • • • 
 
 8 
 
 • • • • 
 
 85 
 
 • • • • 
 
 5 
 
 • • • • 
 
 90 
 
 • • • • 
 
 4 
 
 • • • • 
 
 1846-1850 . 
 
 78 
 
 78 
 
 7 
 
 8 
 
 86 
 
 85 
 
 5 
 
 5 
 
 90 
 
 90 
 
 4 
 
 4 
 
 1851-1855 . 
 
 79 
 
 • • • • 
 
 7 
 
 • • • • 
 
 86 
 
 t • • • 
 
 5 
 
 • • • * 
 
 91 
 
 • • • • 
 
 4 
 
 • • • • 
 
 1856-1860 . 
 
 78 
 
 78 
 
 7 
 
 7 
 
 85 
 
 85 
 
 5 
 
 5 
 
 90 
 
 90 
 
 5 
 
 5 
 
 1861-1865 . 
 
 76 
 
 • • • • 
 
 7 
 
 • • • • 
 
 84 
 
 • • • • 
 
 5 
 
 • • • • 
 
 89 
 
 • • • • 
 
 5 
 
 • • • • 
 
 1866-1870 . 
 
 75 
 
 76 
 
 8 
 
 7 
 
 83 
 
 83 
 
 6 
 
 6 
 
 89 
 
 89 
 
 5 
 
 5 
 
 1871-1875 . 
 
 75 
 
 • • • • 
 
 7 
 
 • • • • 
 
 82 
 
 • • • • 
 
 6 
 
 • • • • 
 
 88 
 
 • « • • 
 
 6 
 
 • • • • 
 
 1876-1880 . 
 
 73 
 
 74 
 
 6 
 
 7 
 
 80 
 
 81 
 
 6 
 
 6 
 
 86 
 
 87 
 
 6 
 
 6 
 
 1881-1885 . 
 
 71 
 
 • • • • 
 
 6 
 
 • • • • 
 
 78 
 
 • • • • 
 
 7 
 
 • • • • 
 
 84 
 
 • • • • 
 
 7 
 
 • • • • 
 
 1886-1890 . 
 
 67 
 
 69 
 
 7 
 
 7 
 
 74 
 
 76 
 
 7 
 
 7 
 
 82 
 
 83 
 
 9 
 
 8 
 
 1891-1895 . 
 
 63 
 
 » • • • 
 
 8 
 
 • • • • 
 
 71 
 
 • • • • 
 
 8 
 
 • • • • 
 
 79 
 
 • • • • 
 
 9 
 
 • • • • 
 
 1896-1900 . 
 
 61 
 
 62 
 
 8 
 
 8 
 
 69 
 
 70 
 
 9 
 
 9 
 
 78 
 
 79 
 
 9 
 
 9 
 
 1901-1905 . 
 
 56 
 
 • • • • 
 
 10 
 
 • • • • 
 
 66 
 
 • • • • 
 
 10 
 
 • • • • 
 
 76 
 
 • • • • 
 
 11 
 
 • • • • 
 
 1906-1910 . 
 
 53 
 
 55 
 
 10 
 
 10 
 
 64 
 
 65 
 
 11 
 
 10 
 
 74 
 
 75 
 
 11 
 
 11 
 
 1911-1915 . 
 
 48 
 
 • • • • 
 
 11 
 
 • • • • 
 
 59 
 
 • • • • 
 
 12 
 
 • • • • 
 
 71 
 
 • • • • 
 
 13 
 
 • • • • 
 
 1916-1920 . 
 
 48 
 
 48 
 
 11 
 
 11 
 
 59 
 
 59 
 
 12 
 
 12 
 
 71 
 
 71 
 
 13 
 
 13 
 
 • 
 
 — 14 
 
 +127 
 
 — 
 
 8 
 
 +55 
 
 
 4 
 
 +47 
 
 Period. 
 
 Under 
 
 70 years. 
 
 70 years 
 and over. 
 
 70 to 79 
 years. 
 
 80 to 89 
 years. 
 
 90 to 99 
 years- 
 
 100 years 
 and over. 
 
 By 5-year 
 periods. 
 
 By 10-year 
 periods. 
 
 By 5-year 
 periods. 
 
 ‘ ■ 
 
 By 10-year 
 periods. 
 
 By 5-year 
 periods. 
 
 By 10-year 
 periods. 
 
 By 5-year 
 periods. 
 
 By 10-year 
 periods. 
 
 By 5-year 
 periods. 
 
 By 10-year 
 periods. 
 
 By 5-.vear 
 periods. 
 
 By 10-year 
 periods- 
 
 1814-1815 . 
 
 95 
 
 • • • • 
 
 5 
 
 • • • • 
 
 3 
 
 • • 
 
 
 1 
 
 • • • • 
 
 .27 
 
 
 .04 
 
 
 1816-1820 . 
 
 96 
 
 96 
 
 4 
 
 4 
 
 2 
 
 
 2 
 
 2 
 
 2 
 
 .44 
 
 .39 
 
 .12 
 
 .07 
 
 1821-1825 . 
 
 94 
 
 • • • • 
 
 6 
 
 • • • • 
 
 3 
 
 • • 
 
 , # 
 
 2 
 
 • • • • 
 
 .50 
 
 • • • • 
 
 .17 
 
 .... 
 
 1826-1830 . 
 
 94 
 
 94 
 
 6 
 
 6 
 
 3 
 
 
 3 
 
 2 
 
 2 
 
 .41 
 
 .45 
 
 .16 
 
 .17 
 
 1831-1835 . 
 
 94 
 
 • • • • 
 
 6 
 
 • • • • 
 
 3 
 
 • • 
 
 # # 
 
 2 
 
 • • • • 
 
 .36 
 
 • • • • 
 
 .23 
 
 • • • • 
 
 1836-1840 . 
 
 94 
 
 94 
 
 6 
 
 6 
 
 3 
 
 
 3 
 
 2 
 
 2 
 
 .34 
 
 .35 
 
 .14 
 
 .19 
 
 1841-1845 . 
 
 95 
 
 • • • • 
 
 5 
 
 • • • • 
 
 3 
 
 • • 
 
 
 2 
 
 • • • • 
 
 .42 
 
 • • • • 
 
 .20 
 
 • • • • 
 
 1846-1850 . 
 
 94 
 
 95 
 
 6 
 
 5 
 
 3 
 
 
 3 
 
 2 
 
 2 
 
 .42 
 
 .42 
 
 .13 
 
 .17 
 
 1851-1855 . 
 
 95 
 
 • • • • 
 
 5 
 
 • • • « 
 
 3 
 
 • • 
 
 
 1 
 
 • • • • 
 
 .37 
 
 .... 
 
 .12 
 
 • • • • 
 
 1856-1860 . 
 
 94 
 
 95 
 
 6 
 
 5 
 
 3 
 
 
 3 
 
 2 
 
 2 
 
 .36 
 
 .37 
 
 .12 
 
 .12 
 
 1861-1865 . 
 
 94 
 
 • • • • 
 
 6 
 
 • • • • 
 
 4 
 
 • • 
 
 # # 
 
 2 
 
 • • • • 
 
 .43 
 
 .... 
 
 .16 
 
 • • • • 
 
 1866-1870 . 
 
 94 
 
 94 
 
 6 
 
 6 
 
 4 
 
 
 4 
 
 2 
 
 2 
 
 .35 
 
 .39 
 
 .04 
 
 .10 
 
 1871-1875 . 
 
 94 
 
 • • • • 
 
 7 
 
 • • • • 
 
 4 
 
 • • 
 
 • # 
 
 2 
 
 • • • • 
 
 .46 
 
 .... 
 
 .08 
 
 .... 
 
 1876-1880 . 
 
 92 
 
 93 
 
 8 
 
 7 
 
 5 
 
 
 5 
 
 2 
 
 2 
 
 .38 
 
 .42 
 
 .10 
 
 .09 
 
 1881-1885 . 
 
 91 
 
 • • • • 
 
 9 
 
 • • • • 
 
 6 
 
 
 # # 
 
 3 
 
 • • • • 
 
 .36 
 
 • • • • 
 
 .05 
 
 • • • • 
 
 1886-1890 . 
 
 91 
 
 91 
 
 9 
 
 9 
 
 6 
 
 
 6 
 
 3 
 
 3 
 
 .38 
 
 .37 
 
 .05 
 
 .05 
 
 1891-1895 . 
 
 88 
 
 • • • • 
 
 12 
 
 • • • • 
 
 8 
 
 • • 
 
 # # 
 
 4 
 
 • • • • 
 
 .56 
 
 • • • • 
 
 .05 
 
 • • • • 
 
 1896-1900 . 
 
 88 
 
 88 
 
 12 
 
 12 
 
 8 
 
 
 8 
 
 4 
 
 4 
 
 .55 
 
 .56 
 
 .03 
 
 .04 
 
 1901-1905 . 
 
 86 
 
 • • • • 
 
 14 
 
 • • • • 
 
 9 
 
 • • 
 
 
 4 
 
 • • • • 
 
 .53 
 
 » • • • 
 
 .08 
 
 • • • • 
 
 1906-1910 . 
 
 86 
 
 86 
 
 14 
 
 14 
 
 9 
 
 
 9 
 
 4 
 
 4 
 
 .59 
 
 .59 
 
 .05 
 
 .07 
 
 1911-1915 . 
 
 84 
 
 • • • • 
 
 16 
 
 • • • • 
 
 11 
 
 • • 
 
 
 5 
 
 • • • • 
 
 .69 
 
 .... 
 
 .04 
 
 .... 
 
 1916-1920 . 
 
 84 
 
 84 
 
 16 
 
 16 
 
 11 
 
 
 11 
 
 4 
 
 5 
 
 .61 
 
 .65 
 
 .03 
 
 .04 
 
 * 
 
 
 L 
 
 +90 
 
 +37 
 
 +67 
 
 * Percentage of changes in age distribution of deaths from all causes dependent upon per¬ 
 centage of changes in age distribution of population from 1850 to 1920. 
 
 Plus signs denote percentage of increase and minus signs denote percentage of decrease. 
 
 (525) 
 
526 PUBLIC HEALTH ADMINISTRATION", ETC., IN BALTIMORE 
 
 uals in the whole population in each age-group was subject, both as regards 
 shorter and longer periods of time (as the result of changes in the birth, 
 immigration, and death-rates, general as well as selective for age), to varia¬ 
 tions not inconsiderable. To illustrate: for any particular age-group at one 
 time the larger proportion of individuals or of deaths, as the case may be, may 
 fall in its earlier portion, or at its center, and at another time may cluster 
 near its upper boundary. Other things remaining equal, the broader the age- 
 group, the wider the opportunities for such variations. 
 
 It is evident that a small percentage of deaths in one or more age-groups 
 in one year or in a short series of years might well be due in large part, at 
 least, to an unusually heavy depletion by death in the period immediately 
 preceding, or conversely, that a large increase of deaths at one period in a 
 particular age-group might be causally associated with the accumulation in it 
 during a period of low mortality of a comparatively large number of vul- 
 nerables. However, these objections apply less weightily to the consideration 
 of the results as measured for single age-groupings over long periods or for 
 multiple age-groupings, as for instance, the total for ail ages below the 
 thirtieth, fortieth, or fiftieth years of life, over either long or short intervals 
 of time. As, on the whole, changes in the proportional age distribution in 
 respect of 10-year age groupings, though often considerable in the aggregate, 
 took place comparatively slowly, if the ratio of deaths in large age-groupings 
 to the total deaths at all ages follows definite trends over long periods of 
 time, it would appear that errors inherent in this method must be largely 
 balanced and the logical inferences drawn from the evidence will be measur¬ 
 ably correct. If these tally in general tenor with rates specific for age that 
 have been obtained for the census years, their value will be greatly increased. 
 In comparing these results with similar material for other cities, it is essential 
 to recall that these figures include deaths in a mixed population of whites and 
 negroes, and that with the exception of certain short periods the mortality 
 in the latter was always much higher than in the former. 
 
 From even the most cursory study of table 138 it is evident that the percent¬ 
 ages of deaths in the various age-groupings often fluctuate within relatively 
 wide limits, that on the whole in the earlier and mid-years of the period under 
 consideration, the proportion of deaths in the age-groups below middle life 
 was very high and the proportion above this period of life was relatively low. 
 After 1875, especially, the latter group gained and the former lost in impor¬ 
 tance. In 1816, one of the most unfavorable years for the earlier years of 
 life, the percentages of deaths in the various important age-groups were: 
 Under 1 year 36.2, under 5 years 49.7, under 10 years 53.8, under 40 years 
 87.5, under 50 years 91.5. In 1822 the percentages of deaths had fallen, 
 under 1 year to 15.8, under 5 years to 28, under 10 years to 32, under 40 years 
 to 73, and under 50 years to 83.9. In 1875 the proportions were: Under 1 
 year 30.5, under 5 years 47.2, under 10 years 54.2, under 40 years 73.7, 
 under 50 years 80.1. By 1920 the proportions were markedly changed, as 
 follows: Under 1 year 17.5, under 5 years 23.3, under 10 years 25.1, under 
 40 years 45.9, under 50 years 56.3. And similarly, in other years, very great 
 variations occurred in the proportion of deaths in all the age-groups. 
 
 Turning to the percentages averaged for 5- and 10-year periods (table 
 139 and graphs 39 and 40), it will be observed that the proportion of deaths 
 
GENERAL CONCLUSIONS 
 
 527 
 
 YEAR 
 
 Graph 39 (from table 139). Averages, by 10-year periods, of percentages 
 of deaths by specified age-periods of total deaths from all causes, from 1814 
 to 1920, inclusive. 
 
 YEAR 
 
 Graph 40 (from table 139). Averages, by 10-year periods, of the per¬ 
 centages of deaths under certain ages to total deaths, from 1814 to 1920, 
 inclusive. 
 
528 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 within the various age-groups, as well as under certain ages, followed very 
 definite trends. On account of the greater smoothness of their curves, discus¬ 
 sion will be confined to the rates as averaged, for 10-year periods. For the age- 
 groups under 1, 0 to 5, and 0 to 10, after a decided decline between 1820 and 
 1830, the percentage rose for several decades (until 1860 in the two latter 
 groups) and thereafter declined continuously and markedly to the end. In 
 the second decade of life, except for a slight rise in 1880, the decline in the 
 proportion of deaths was continuous. A similar fall characterized the course 
 for the age-group 20 to 29 years until 1900, after which the proportion rose 
 in a moderate degree. For all the age-groups above the thirtieth year there 
 was a considerable rise between 1820 and 1830, followed by a gradual decline 
 to a lower level, reached usually between 1860 and 1880. This decline was 
 invariably succeeded by an ascent which, in the higher age-groups, was very 
 considerable. The proportionate increase for the various decades of life 
 between 1850 and 1920, in percentages, was for the fourth, nothing; in the 
 fifth, 37; in the sixth, 140; in the seventh, 222; in the eighth, 267; in the 
 ninth, 100. Similarly, the percentage of decline was in the first decade, 51; 
 in the second, 33, and in the third, nothing. 
 
 Following, now, the course of the percentages of deaths under 1, 2, 5, and 
 10 years and each succeeding decade of life to the sixtieth year, it is found 
 that for each category there was a sharp decline between 1820 and 1830, 
 followed by a gradual ascent to a peak reached in 1850 or 1860, and suc¬ 
 ceeded by a continuous and even decline to 1920. The percentages of this 
 decline were from 1850 to 1920, under 1 year, 41; under 2 years, 45; under 
 the fifth and tenth years, 45; under the twentieth year, 50; under the thirtieth, 
 47; under the fortieth, 42; under the fiftieth, 34; under the sixtieth, 24; 
 under the seventieth, 13. In this same period there was an increase of 300 
 in the percentage of deaths in the age-group 70 years and over. When allow¬ 
 ances are made for the changes in the proportional distribution of the popu¬ 
 lation among the various age-groups in the census years 1850 to 1920 (see 
 table 10) it appears that in this period the percentages of decline of these 
 death-ratios dependent upon the age-factor alone were for under 1 year, 48; 
 from 1 to 4 years, 41; under 5 years, 67; from 5 to 9 years, 34; and the first 
 two decades of life, 61 and 64, respectively. Between the twentieth and 
 fortieth years of life the death ratios did not vary and the percentages of 
 change in these age-groups of the population were insignificant. In the fifth, 
 sixth, seventh, and eighth decades and 80 years and over, 127, 55, 47, 37, and 
 67 per cent, respectively, of the increase in the death ratios were attributable 
 to the percentages of proportional increases in the corresponding age-groups 
 of the population. From the foregoing analysis the conclusion is warranted 
 that, when corrected for the known changes in the age distribution of the popu¬ 
 lation, the trends of these ratios accord in a general way with the courses of the 
 rates specific for the corresponding age groups for the census years, confirm the 
 deductions drawn from the latter, and indicate the proportion of the observed 
 decline in the total mortality which was due to causes other than the age 
 factor. 
 
 At this point it will be instructive to consider the influence upon the 
 mortality-rate from all causes of those great groups of maladies whose courses 
 may be followed from the beginning. This comparison, in rates averaged for 
 
GENERAL CONCLUSIONS 
 
 529 
 
 5-year periods, is made in graph 41. Of the seven groups, each composed of 
 several distinct affections, five belong without question wholly to the infec¬ 
 tions. Of the remaining two, in one, violence, infection plays primarily no 
 part, and in the other, certain diseases peculiar to infancy, the role of infec¬ 
 tions is a subsidiary one. In most of these groups there is at least one affection 
 the death-rate of which might have been favorably influenced within the 
 period under discussion by either medical treatment or by some forms of 
 administrative activities. It will be observed that the curve for all causes of 
 death presents five distinct w r aves: the first from 1812 to 1830, the second 
 from 1831 to 1845, the third from 1846 to 1865, the fourth from 1866 to 
 
 Graph 41 (from tables 18, 20, 43, 61, 79, 123, 129, and 133). A comparison, 
 in crude rates averaged for 5-year periods, of the contribution of seven 
 important groups of diseases to the total mortality from all causes, from 
 1812 to 1920. inclusive. 
 
 1880, and the fifth from 1881 to 1915. In comparing the curves for each 
 of these groups with that for all causes, there appear certain striking corre¬ 
 spondences which in large part may explain the latter. In the first wave the 
 rise and fall in the mortality-rates for all causes is definitely assoeiatecl with 
 similar changes in the rates for insect-borne, intestinal, and acute respiratory 
 diseases and for tuberculosis. Violence conforms in less degree, but exanthe¬ 
 matous diseases and certain diseases of infancy not at all. In the second wave, 
 intestinal and exanthematous diseases, affections of early infancy and tuber¬ 
 culosis conform distinctly with all causes. In the third wave, while intestinal, 
 respiratory, and exanthematous diseases follow the curve for all causes most 
 conspicuously and exactly, all the other groups, except early infancy, display 
 
530 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 rises and falls. The same phenomena are repeated in the fourth wave. In 
 the gradual descent between 1881 and 1915 in the curve for all causes, insect- 
 borne, intestinal, and exanthematous diseases showed marked recessions, while 
 tuberculosis, acute respiratory diseases, and diseases of early infancy declined 
 sensibly. Violence, on the other hand, rose gradually. The distinct rise since 
 1916 in the rate for all causes was associated very definitely with increases in 
 the rates for acute respiratory and the exanthematous diseases (influenza) 
 and violence. 
 
 While it may not be claimed that these groups of affections were the sole 
 causes, it does appear that they were mainly responsible for the high mortality- 
 rates, and that, embracing as they do all the more important factors concerned 
 in rapidly fluctuating rates, they represent the main elements of elasticity in 
 the total mortality-rates. Other things remaining equal, it is mainly through 
 these groups of causes that the total death-rate may be seriously affected by 
 either natural or artificial means, so far known. As they have regressed in 
 importance as causes of death, the total mortality-rates have not only fallen, 
 but tended to stabilize. As these groups have both contributed in very large 
 proportion to the total deaths and represented the chief factors of elasticity 
 in the death-rate from all causes, their disappearance, or even their further 
 serious diminution in lethal force, would result in the stabilization of the total 
 death-rate at a yet lower level. 
 
Chapter XX.—Summary and Conclusions. 
 
 The febrile diseases; Affections peculiar to child-birth and to early in¬ 
 fancy; Violence; The chronic organic diseases. (Tables 140 and 141.) 
 
 It now remains to summarize and to correlate the essential facts collected 
 and analyzed in the foregoing chapters, with the design of reaching general¬ 
 izations from which instructive lessons may be deduced. 
 
 The febrile diseases .—On both historical and practical grounds it is con¬ 
 venient to consider first the febrile diseases, concerning which certain impor¬ 
 tant facts stand out with striking clearness. Without exception, the course of 
 each particular disease studied has been marked by advances and recessions 
 of mortality which have flowed and ebbed in series of tides of uneven volume 
 and force. A few have advanced and receded like tidal waves; others have 
 pursued a less uneven course. For many of them similar courses can be 
 traced for morbidity. When measured by rates specific for age, race, and sex 
 these characteristics persist. For certain groups of these diseases, especially 
 those in which transmission appears to be confined largely if not entirely to 
 direct contact through individuals, these characters, while modified in degree, 
 have not been changed in quality by any artificial barriers that have been set 
 up from time to time. In the case of each particular disease of this class, except 
 pneumonia and influenza, that can be followed continuously over a long term 
 of years, mortality-rates have fallen conspicuously since 1885 or 1890, and by 
 the end of the period embraced in this study are at or near their lowest ebb. 
 In the case of all of the important febrile diseases, importation from without 
 has been an important factor. As between the two great groups of these 
 diseases, these changes in incidence and mortality have occurred, on the whole, 
 in different fashions for the nuisance and the contactive diseases; in the 
 former the declines were gradual, while in the latter, as measured in terms of 
 mortality at least, the decreases were comparatively abrupt. 
 
 Considering first the diseases whose spread is governed so largely by environ¬ 
 mental conditions, the nuisance diseases in the broad sense, attempts at arti¬ 
 ficial interference were rewarded by a considerable measure of success after 
 a long and poorly managed campaign. The efforts, correct in principle, directed 
 against the mosquito-borne diseases, were more determined and persistent, 
 and consequently were sooner affective. However, owing to the natural history 
 of these diseases, the problems were simpler. With yellow fever the obstacles 
 to be overcome were less difficult, for the following reasons: The high case- 
 fatality rate and short interval between invasion and death diminished oppor¬ 
 tunity of spread; the apparent inability of the stegomyia mosquito to breed 
 in numbers except at Fell’s Point, long the sole place of docking of ships 
 from infected ports, tended to confine the disease to this locality except under 
 unusual conditions of wind; the complete recovery without becoming carriers 
 of those who survived, and the effect of cold upon this species of mosquito, 
 cmbined to make it practically impossible for the disease to survive the winter; 
 
 531 
 
532 PUBLIC HEALTH ADMINISTRATION", ETC., IN BALTIMORE 
 
 the disease was usually imported over a great distance, from places where its 
 prevalence has greatly diminished and from which trade has decreased. 
 
 Malaria, on the other hand, was indigenous, and conditions for frequent 
 importation from near and far were peculiarly favorable; case-fatality also 
 was relatively lower, and many infected individuals carried the parasites over 
 the winter season; and the malaria-carrying species of mosquitoes were abun¬ 
 dant and widely spread in the city, over a large part of which conditions were 
 for many years particularly favorable for their multiplication. The influence 
 of importation of the disease upon both prevalence and severity of attack 
 and of cinchona upon its cure and final eradication can hardly be over¬ 
 estimated. When the disease was at its zenith in incidence and mortality, 
 cinchona was scarce and expensive; in the period of decline, importation had 
 fallen off, cinchona preparations were abundant and cheap, and conditions 
 favorable to extensive mosquito breeding were gradually reduced to a com¬ 
 paratively low point. 
 
 In this connection, there remains to be considered yet another factor, namely, 
 the possible inability of the malignant types of malarial parasites to preserve 
 their lethal force for an indefinite period in an uncongenial climate. Experi¬ 
 ence has demonstrated that the victims of severe chronic malaria acquired in 
 tropical or subtropical countries, and which has resisted specific treatment, 
 often improve and gradually recover after prolonged residence in cooler cli¬ 
 mates. It is conceivable that the action of the latter, whatever its character, 
 may be exerted deleteriously upon the parasite as well as beneficially upon the 
 host, as is commonly believed. Therefore it is not improbable that virulent 
 types of malarial parasites imported from the West Indies, South and Central 
 America, and the South Atlantic and Gulf States became so modified in the 
 bodies of their local hosts during the relatively severe winters of Baltimore 
 that, when transferred to new hosts with the reappearance of mosquitoes in 
 successive summers, while preserving their infective qualities, they suffered a 
 reduction in their lethal force. Such modifications may have been either rapid 
 or gradual. Modifications in virulence may have been induced, in part at least, 
 by the deprivation in the northern climate during several months in the year 
 of the accustomed opportunity of the parasites constantly enjoyed in hot 
 climates, for frequent change to new human hosts and for possible reorganiza¬ 
 tions in the bodies of new mosquito hosts necessary for the preservation of their 
 virulence to man. 
 
 With typhus fever, frequently imported, long endemic, and often occurring 
 in serious epidemic outbreaks, neither sanitary measures nor specific treat¬ 
 ment come into consideration. Without serious attempt at artificial inter¬ 
 ference, it died out and afterwards, when awakened again after long slumber 
 or when reintroduced from without, it has invariably failed to spread, although, 
 as proven by the results of inspection of school children, a not inconsiderable 
 proportion of the population was louse infested. 
 
 For the second group of the typically nuisance-borne diseases, the acute 
 intestinal affections, progress was slower. So far as general sanitation is con¬ 
 cerned this was due not so much to deficiency in knowledge, but to lack of 
 appreciation on the part of the public of existing information concerning 
 the importance of sanitary measures. The situation was greatly complicated 
 
GENERAL CONCLUSIONS 
 
 533 
 
 by the rapid growth of population, the great cost of overcoming the consider¬ 
 able physical difficulties involved, and the continued reimportation on a large 
 scale of all of these diseases, save cholera. This factor continues to the present 
 day to be of considerable importance in connection with typhoid fever. The 
 mortality from the group as a whole was high at the outset, and, running in a 
 series of waves, reached a comparatively low point by 1840. Then, after a 
 period of heavy immigration, associated with the importation of cholera, 
 typhoid fever and dysentery, mortality attained its acme by 1855. But for a 
 slight setback between 1886 and 1890, its decline has been steady since 1875. 
 As judged by mortality, their courses reflect, on the whole, at any given period 
 during the 109 years over which it may be followed, the state of general sanita¬ 
 tion in regard to water and milk supplies, the disposal of night-soil, the extent 
 of fly breeding, the degree of importation of cases and of infected foods, and 
 the efficacy of medical and nursing care. Administrative control of persons ill 
 of these diseases has played no part in the result,, except in the case of cholera 
 in 1866 and of typhoid fever since 1916. That the improvements since 1890 
 in medical management and nursing in typhoid fever and cholera infantum 
 and in the feeding and care of infants have exerted a favorable influence upon 
 mortality from these affections can not be questioned. The continued mor¬ 
 bidity of typhoid fever among individuals in whom extra-urban infection can 
 be excluded and of cholera infantum, and the occasional epidemics of dysen¬ 
 tery among infants, since the revolution in connection with the control of 
 water, milk and night-soil, and the notable decrease in flies, all effective since 
 1917, suggest very strongly that transmission of their causal agents from 
 person to person is now limited very largely to contact, either directly or 
 indirectly, through foods infected in households. 
 
 Turning now to the contactive diseases and considering first the two groups, 
 the exanthematous and the acute respiratory affections, in which the trans¬ 
 mission of the causal agents is apparently restricted largely if not completely 
 to personal contact with the sick or with carriers, it will be recalled that condi¬ 
 tions were entirely different. While the former group as a whole exhibited 
 a marked decline in mortality between 1875 and 1915, and had indeed by the 
 latter date become relatively unimportant, in the quinquennium ending in 
 1920 the mortality for the latter exceeded the levels of 1812-1820 and 
 1826-1830. 
 
 The course of the diseases of the first or exanthematous group is remark¬ 
 able chiefly in the following respects: Each important member, i. e., small¬ 
 pox, measles, scarlatina, and influenza, after repeated epidemic visitations, 
 finally achieved endemicity and caused considerable mortality. Two, scarlet 
 fever and measles, without artificial interference afterwards fell to negligible 
 grades of mortality. One, small-pox, after a long period of endemicity dis¬ 
 appeared completely, only to reappear twice (1872-1873, 1882-1883) in 
 severely fatal, and twice again in milder epidemics. This disease flourished 
 and declined under a laissez-faire vaccination policy; subsided after vigorous 
 vaccination campaigns; and, though frequently reintroduced, has failed to 
 become a serious menace since the adoption, with the use of potent virus, of a 
 vaccination policy of a moderate degree of effectiveness in regard to general 
 vaccination of children and revaccination of adults. The records show that 
 
534 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 while epidemic small-pox attacked some individuals who had good recent vacci¬ 
 nation scars and a considerable number who had been vaccinated many years 
 before, the former were invariably but slightly ill and among the latter the 
 mortality was much lighter than among the unvaccinated. It appears also 
 that an attack of small-pox itself by no means always conferred lasting 
 immunity, for in severe epidemics varioloid, though rarely fatal, was by no 
 means-uncommon. The evidence at hand indicates that the decline in the 
 incidence and the mortality from small-pox was closely correlated with the 
 wider adoption of vaccination with improved virus. 
 
 Though both measles and scarlet fever have declined conspicuously in mor¬ 
 tality since 1880, they have increased greatly in invasive capacity or attack- 
 rate. In this respect they are in singular contrast to typhus fever, which dis¬ 
 appeared spontaneously and has repeatedly failed to spread after reimporta¬ 
 tion. Chicken-pox has shown no decline in morbidity during the 20 years for 
 which records exist. Influenza, after repeated epidemic waves, finally became 
 endemic, with a fluctuating but always appreciable mortality-rate since 1890. 
 Since the pandemic of 1918, endemic influenza has risen above the previous 
 levels in both incidence and lethal force. Members of this group of diseases 
 have been imported frequently not only as epidemics, but many of them more 
 or less constantly while endemic. 
 
 The group of acute respiratory diseases declined in mortality from the high 
 level of 1812-1820 to a comparatively low point by 1826-1830, and continued 
 to rise almost unbrokenly until 1881-1885. Thereafter their mortality-rate 
 fell steadily until 1911-1915, but in the last quinquennium there was a 
 decided reaction. The increase in mortality between 1831 and 1885 was 
 shared by all three members of this group, but the decline between 1886 and 
 1915 was restricted to whooping-cough and diphtheria, while pneumonia 
 remained relatively stationary. The ascent in mortality after 1915 was due 
 almost entirely to pneumonia. All three diseases were endemically established 
 prior to 1812, and their importation has been unrestricted from the beginning. 
 
 Since no measures of restriction have been attempted against pneumonia, 
 and the inadequate efforts to interfere with whooping-cough date from 1916, 
 the courses of these diseases reflect their actual natural history in this popula¬ 
 tion. While diphtheria had fallen decidedly in mortality before the introduc¬ 
 tion of intubation and of antitoxin in the last decade of the nineteenth 
 century, considerable credit must be given these two measures in connection 
 with the very decided secondary fall, which has occurred since 1895. Not¬ 
 withstanding the institution of restrictive measures in 1898 and their con¬ 
 tinuous amplification since this date, morbidity, on the other hand, has not 
 followed the course of mortality, but has gradually increased in recent years. 
 
 Of the remaining acute communicable diseases which are or seem to be¬ 
 spread largely if not entirely by contact, epidemic meningitis, erysipelas, and 
 puerperal septicemia have declined in incidence and mortality in recent years, 
 while poliomyelitis has come into prominence for the first time. Since no 
 administrative measures have been directed to the control of erysipelas and 
 puerperal infection, declines in incidence and mortality from these must be 
 attributed partly to their natural history and partly to the development and 
 practice of antisepsis since about 1890. Restrictive measures and antiserum 
 
GENERAL CONCLUSIONS 
 
 535 
 
 treatment may have been instrumental in controlling epidemic meningitis 
 in the slight revival of this disease in 1917. There is no evidence that efforts 
 at artificial control exerted any influence upon the course of poliomyelitis in 
 and since 1916. 
 
 Critical analysis of recorded data indicates that the observed changes in the 
 death-rate from tuberculosis have not been appreciably influenced by improve¬ 
 ments in general sanitation nor by restrictive and other measures applied to 
 persons and their environment since 1910. A decided decline in the mortality 
 from tetanus coincides with the development and use of antisepsis and of 
 prophylactic treatment with antitoxin, and the control of the use of explosive 
 crackers and caps by children. 
 
 It is notable that the diseases whose courses have been unaffected by artificial 
 interferences, but which have at the same time shown the most conspicuous 
 declines in mortality, are affections which are distinctly general or systemic 
 and without specific local inflammatory reactions. In this respect compare 
 measles, scarlet fever, and typhus with whooping-cough and pneumonia. 
 Among the affections which have been subject to artificial interferences the 
 same holds true, as is illustrated by comparison of malaria and yellow fever 
 with the intestinal diseases, diphtheria, and pulmonary tuberculosis. 
 
 The record shows very clearly that, with the exception of small-pox, no 
 attempts were made to control the spread of any of the contactive diseases by 
 isolation of the sick and their contacts until the closing years of the nineteenth 
 century, and that before 1910 all efforts in this direction were imperfect in 
 execution. It has been shown that for most of these diseases such practices at 
 best can in the nature of the case do no more than prevent association of the 
 sick and their household contacts with the general public for the period 
 between diagnosis and death or recovery, and can rarely cover the periods of 
 incubation and the indeterminate carrier stage, except for diphtheria and epi¬ 
 demic meningitis. The extensive systems of disinfection of household and insti¬ 
 tutions with formaldehyde gas and of sterilization of garments and bedding by 
 steam or their destruction by fire have signally failed to exercise appreciable 
 influence upon the spread of the causal agents of a single disease. Long before 
 these practices were put into effect the mortality of each and every one 
 of the diseases upon which they were tried had declined conspicuously, and 
 since these activities were instituted the morbidity of most of them has 
 increased decidedly. Upon tuberculosis, against which, since 1910, with the 
 exception of diphtheria, the greatest and most costly efforts have been expended, 
 no appreciable impression lias been made by these specific measures. 
 
 Hospitalization of cases of acute contactive diseases has without doubt 
 resulted in many recoveries, especially in recent years, but on account of the 
 relatively small scale upon which it has been practiced, if for no other reason, 
 this procedure can not have materially influenced morbidity. In the few 
 diseases of this class, such for instance as diphtheria, scarlet fever, tubercu¬ 
 losis, actinomycosis, and anthrax, whose causal agents may be transmitted by 
 the mediation of foods as well as by contact with infected human beings, and 
 for some of them with lower animals, the methods of restriction developed 
 within the last 10 years against the typically food-borne diseases have doubt¬ 
 less narrowed this avenue of infection. 
 
536 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 In the period under review, the scope and character of the investigation of 
 school children in practice can have had no effect upon the control of the com¬ 
 mon contactive diseases in individuals of this age. It is pertinent to remark 
 in this connection that even the most elaborate system of inspection of school 
 children with the exclusion of those found ill could not by any possibility 
 seriously control morbidity from these diseases, for this crucial reason—the 
 chief incidence of all the important diseases of this class is in the age-group 
 below school age. It would appear, indeed, that the supposed correlation in 
 time between the opening of schools and the increase of the various com¬ 
 municable diseases of childhood either does not exist in fact or is spurious. 
 These seasonal variations of incidence were well established before there were 
 schools for the larger part of the child population, and for but one of the 
 affections under discussion (diphtheria) does the attack-rate usually increase 
 significantly in the early fall. For most of them the acme is reached in the 
 late winter or spring. That the morbidity from these diseases may be reduced 
 in some comparatively small degree by a constant and close inspection of 
 children in school, followed by exclusion of recognized cases may be granted, 
 but in the cities where it has been adopted there is no evidence that over a term 
 of years the morbidity-rate has been seriously affected. Among other reasons, 
 the other sources of contact in a large community are sufficiently great for the 
 transmission of the causal agents of these affections. For the occasional pro¬ 
 tection of a few individuals the procedure is undeniably effective, but the point 
 here insisted upon is that for the mass of individuals composing the most 
 susceptible portion of the population it can afford no really adequate and 
 permanent defence. The intelligent use of detention wards for candidates 
 for admission has seemed to prevent the entrance over long periods of time of 
 certain of these affections into closed institutions harboring young children, 
 and this procedure is reasonable. 
 
 In regard to the introduction from without, it has been shown that until 
 very recent years maritime quarantine afforded a very ineffectual barrier. It 
 not only failed to hold against the particular diseases it was designed to 
 exclude, but overlooked many more which it should have kept out. Nor have 
 other portals been protected. With the exception of plague, every communi¬ 
 cable disease, from yellow fever to leprosy, prevalent in the United States, 
 has entered from time to time by Baltimore’s back or side doors. Nor is it 
 possible to prevent this, and the reverse is equally true. The important diseases 
 dealt with in this free interchange are malarial, yellow, typhus, scarlet, and 
 typhoid fevers, cholera, dysentery, diarrhoea, small-pox, chicken-pox, measles, 
 influenza* diphtheria, whooping-cough, pneumonia, meningitis, poliomyelitis, 
 tuberculosis, and the venereal diseases. 
 
 The official mortality-rates from yellow fever, typhus fever, small-pox, and 
 tuberculosis have been materially reduced as the result of exportation of cases 
 to hospitals situated without the city limits. 
 
 In the period under review, except for the prevention of ophthalmia neona¬ 
 torum, no attempts have been made by the health authorities to control the 
 prevalence of the so-called venereal diseases. The Baltimore population has 
 been dominated in this respect by the traditional bonds imposed alike by the 
 fallacies of religious custom and moral prudery, according to which cure of the 
 
GENERAL CONCLUSIONS 
 
 537 
 
 transgressor infected while breaking the illy-kept code of sexual morality is 
 permissible or even laudable; education in methods of prevention are inter¬ 
 dicted. In an age in "which the chief shibboleths are education and personal 
 hygiene, for the important diseases whose natural history best lends itself to 
 the influence of protective measures personally applied, technical instruction 
 in their use is proscribed, although it is well established that promiscuous 
 intercourse, upon which their spread is so largely dependent, shows no signs 
 of actual decrease. 
 
 It will be profitable to inquire into the degree in which improvement in 
 medical treatment and care may have favorably influenced the course of mor¬ 
 tality of the febrile diseases since the opening of the nineteenth century. 
 It is evident that consideration must be given to changes in methods of use as 
 well as in the number and kinds of remedial agencies available at different 
 periods. 
 
 Strictly medical treatment, as opposed to mechanical or surgical measures 
 fall, when reduced to simple terms, into two broad classes, the topical and the 
 systemic. The members of the former class act chiefly as protectives, diluents, 
 detergents, irritants, corrosives, astringents, and antiseptics, and are applied 
 to the skin or to the mucous membranes of the conjunctival, nasal, buccal, 
 faucial, gastro-intestinal, and genito-urinary tracts. Of these, many efficient 
 representatives have been used from time immemorial. In the light of mod¬ 
 ern knowledge, but little curative value may be conceded to them in the 
 exanthematous diseases, pneumonia, whooping-cough, or diphtheria. It is con¬ 
 ceivable that emetics may have influenced in occasional cases the separation 
 and expulsion of the false membranes of laryngeal diphtheria. In diarrhoea and 
 dysentery, and perhaps in cholera, cathartics, astringents, antiseptics, and 
 clysters have undeniably exerted a favorable influence upon mortality. Sim¬ 
 ilarly, in the treatment of gonorrhoea and other infections of the genito¬ 
 urinary tract, and of various pyogenic infections of similar character, some 
 of them have been efficacious. That remedies of this class have been applied, 
 except under the influence of modern surgery, with more skill and judgment 
 in recent than in earlier years may well be questioned. 
 
 The systemic remedies, which, by some means, usually absorption from body 
 surfaces, reach the vascular streams and thus become more or less widely trans¬ 
 ported through the organism, exert their influence upon certain organs and 
 systems directly and upon the system as a whole indirectly. The medicines of 
 this class applicable to the treatment of the febrile diseases may be divided for 
 present purposes into several main classes: The stimulants, such as alcohol, 
 ether, camphor, caffein (in coffee), digitalis, nux vomica; depressants, such 
 as veratrum viride, aconite, mercury; narcotics and hypnotics, such as opium 
 and its derivatives, chloral, the bromides, and the like; the diuretics, such as 
 various salts of potash and soda, squills, and digitalis; diaphoretics, such as 
 camphor, etc.; expectorants, such as various salts and vegetable extracts; 
 tonics, such as iron, arsenic, mercury, cod-liver oil; alteratives, such as the 
 salts of iodine and various vegetable extracts; antispasmodics, such as ether, 
 chloroform, turpentine, assafoedita; specifics, such as cinchona for malaria, 
 mercury for syphilis, ipecac for amoebic dysentery. These are typical repre¬ 
 sentative drugs used internally in the treatment of the febrile diseases during 
 
538 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 most of the nineteenth century. Most of them appear in the Formulae Selectae 
 (67) of Drs. Samuel K. Jennings and Thomas Owings, collected between 
 1808 and 1825. Many other agents, some falling under other classes, were 
 in common use. Some were noxious, some perhaps possessed healing virtue, 
 and many others were inert. With few exceptions, the coal-tar derivatives, 
 introduced in ever-increasing numbers since 1875 and much lauded as febri¬ 
 fuges, can hardly be credited with strictly curative properties in this class of 
 disease. Salicylic acid, used first in oil of gaultheria, appears to exert a 
 specific curative effect in acute articular rheumatism. 
 
 Stimulants in the depression of the acute stages of the febrile diseases and 
 tonics and alteratives in convalescence doubtless often saved life, and the ease 
 from pain conferred by narcotics and hypnotics must be credited with salutary 
 effects. It has been pointed out already that the exhibition of cinchona on the 
 large scale must have been an important if not the chief influence in the 
 great reduction of morbidity and mortality from malaria. It is likely that the 
 routine use of ipecac in the treatment of dysentery was curative in some cases 
 of the amoebic type of this disease. That the curative powers of mercury in 
 syphilis was, until the introduction of salvarsan, the sole artificial influence 
 in lessening the ravages of syphilis can not be denied. The favorable action 
 upon mortality of antisera in diphtheria, tetanus, and epidemic meningitis 
 fell in the twentieth and not in the nineteenth century. So far as the influence 
 of substitution diseases is concerned, hydrophobia has never been epidemic 
 in Baltimore, and but small opportunity has been offered to apply Pasteur’s 
 preventative treatment for this malady. It has been shown that not until 
 after 1882 was vaccination routinely practiced to the degree necessary to 
 control small-pox. 
 
 With the exception of the beneficent use of the few specifics, it is doubtful 
 if, on the whole, so far as drugging and blood-letting in the acute febrile 
 diseases are concerned, physicians did not until recent years kill at least as 
 many of the desperately ill as they benefited. The poisoning by mercury 
 pushed to salivation in diphtheria and pneumonia in particular was certainly 
 responsible for many deaths. There is no evidence that any drugs or other 
 medicaments now or ever used are capable of exerting specific curative effects 
 upon any of the exanthematous diseases, nor upon typhus and typhoid fevers, 
 whooping-cough, pneumonia, bacillary dysentery, cholera, the diarrhoeas 
 and tuberculosis, nor, until the specific antisera came into use, upon diph¬ 
 theria, epidemic meningitis, and tetanus. It may not be denied that in some 
 of these diseases, more particularly in those in which the primary lesions 
 are seated in the intestines, the use of topically applied cleansing, astringent, 
 and antiseptic agents and of stimulants, narcotics, and hypnotics has tided 
 over many individuals sick with these affections during the critical period 
 while active immunity was in process of development. 
 
 To the improvement in the methods of management of those ill with febrile 
 diseases for which no specifics existed, much more credit for reduction in 
 case-fatality is to be given that can be ascribed to the exhibition of drugs. 
 The substitution of careful management of those sick of the febrile diseases 
 for the traditional drastic bleeding, drugging, and other depleting practices 
 was a great step in advance. From small beginnings in earlier years, with 
 
GENERAL. CONCLUSIONS 
 
 539 
 
 the growth of knowledge of pathological anatomy, the “ expectant ” or symp¬ 
 tomatic treatment emerged into prominence by 1875. It was about this time 
 that the medical world rediscovered and began thoughtfully to realize the 
 truth of the ancient doctrine, vis medicatrix natures. Of great service, indi¬ 
 rectly at least, in the reaction against the time-honored practice of depletion 
 in acute febrile diseases was the school of homeopathy. When practiced accord¬ 
 ing to its tenets it commonly amounted to drugless treatment, and thus, though 
 not so realized by its devotees, it was well-nigh identical with that of the 
 school of therapeutic nihilists within the regular profession who based their 
 practice upon the solid ground of pathological anatomy and controlled experi¬ 
 ment. In consequence of these two movements, each resulting in the with¬ 
 holding of depleting remedies and measures, the world had the opportunity 
 to reobserve the important fact that in these affections there is a strong 
 natural tendency to recovery. The revival of the ancient practice of the free 
 use of water, within and without, in acute fevers, of more intelligent feed¬ 
 ing, especially in acute intestinal disorders and in pneumonia and tuberculosis, 
 the improvements in nursing and in hospital facilities, have all had a bene¬ 
 ficial influence in reducing mortality. The methods of the leading physicians 
 in 1880 or 1890 were generally accepted by 1910. The invention, about the 
 middle of the nineteenth century, of the hypodermic syringe, with which reme¬ 
 dies may be introduced rapidly into the system,, has had a most important 
 influence in saving lives and in hastening recovery in certain febrile diseases. 
 The beneficial effects of this method of administering remedial agents were 
 gained first in malaria, syphilis and the diarrhoeal diseases (by accelerating 
 the action of the salts of cinchona, mercury, and opium), and much later this 
 instrument rendered possible the administration of the modern biological 
 remedies conferring active and passive immunity, such as the bacterial and 
 other vaccines and the various immune sera. 
 
 Advances in surgery, or that branch of the medical art that seeks to give 
 relief by the application of mechanical measures, have to a large though not 
 accurately measurable degree favorably influenced fatality rates in certain 
 acute febrile diseases. Its special contributions here have been directed against 
 secondary suppurative foci, such as otitis media, mastoiditis, empyaema, intesti¬ 
 nal perforation, appendicitis; puerperal and gonorrhoeal infections of the 
 female organs of generation; and other suppurative affections of various other 
 abdominal organs; chronic infections of the teeth and tonsils; and in bone, 
 joint, lymph-gland, and serous membrane tuberculosis. To the old operation 
 of tracheotomy and its modern substitute intubation are to be credited many 
 lives rescued from laryngeal diphtheria. In the relief of mechanical obstruc¬ 
 tions, such as concretions of the urinary bladder, kidneys, and the biliary 
 system, of hypertrophies of the prostate, of strangulated hernia, and other 
 causes of intestinal obstruction, the contributions of surgery to the prolonga¬ 
 tion of life have been notable. Particularly in the past 30 years has the 
 mortality from tumors been influenced by surgical means. In connection with 
 injuries of various kinds, surgery has rescued many lives. While the field of 
 surgery has been enormously widened since the introduction of anesthesia, 
 and particularly of antisepsis, and the development of knowledge of pathologi¬ 
 cal anatomy (to which it has made large contributions), a large if not the 
 major part of its general principles are of ancient date. 
 
 35 
 
540 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 In essence, the foregoing picture represents a series of struggles between 
 the individuals of the population on the one hand and groups of parasitic 
 micro-organisms on the other. Many individuals have been attacked repeatedly 
 by different species at separate times, by several species at the same time, and 
 by the same species several times. The severity of these attacks has varied 
 greatly with different individuals and at different periods. In this complex 
 conflict the population, though hard hit at times, has never been seriously 
 menaced, but the invading micro-organisms have often proved unable to 
 maintain the battle even after repeated importation. 
 
 Considering first the population, it will be recalled that it has been found 
 that its members have differed in their natural susceptibility, as judged by 
 both morbidity and mortality, and that of the variables it has been possible 
 to analyze in these respects the most important and constant in their action 
 are associated with age, race, and sex. 
 
 Rates specific for age demonstrate beyond a question of doubt that both 
 morbidity and mortality of measles, scarlet fever, chicken-pox, mumps, 
 whooping-cough, diphtheria, epidemic meningitis, and poliomyelitis are and 
 have been, so far as these records go, largely if not entirely confined to the 
 first decade of life. Indeed for most, though not for all, of these diseases, the 
 heaviest incidence and fatality lie between the seventh month and the fifth 
 year. The relatively high natural immunity to attack and fatality that exists 
 against these diseases during the first 6 months of life suffers a severe loss 
 between the seventh month and the fifth year, but is then gradually recovered, 
 so that after the tenth or fifteenth year the balance is restored, and whatever 
 the degree of exposure, incidence and death are relatively rare. With measles, 
 which of this group of diseases has the highest degree of incidence, a large 
 part of the immunity possessed by the population over the age of 10 is per¬ 
 haps actively acquired as the result of attacks earlier in life. Tetanus and 
 erysipelas belong to this group, and until vaccination was widely adopted, 
 small-pox was doubtless in Baltimore as elsewhere peculiarly a disease of 
 childhood. Concerning malarial, yellow, and typhus fevers, there are no 
 recorded data for estimating the influence of age upon morbidity and mor¬ 
 tality, but from common experience it is well established that the young are 
 particularly susceptible to these diseases when prevalent. Diarrhoea and dysen¬ 
 tery, while attacking all ages, have their heaviest mortality in early life— 
 and with diarrhoea the bulk of the mortality occurs in the first year. While no 
 data concerning the age distribution of cholera are to be found in the records, 
 it is notable that in cholera years the mortality from cholera infantum was 
 particularly high. Typhoid fever and influenza belong to the group of infec¬ 
 tious diseases that attack all ages, but the mortality of the former is rather 
 heavier before than after the fortieth year of age, and the reverse is the case 
 with the latter. 
 
 Pneumonias, both lobar and broncho, are characterized by high incidence 
 and mortality in early life, but for 20 or 30 years after age 10 their rates are 
 low. After the fortieth year, however, they gain renewed strength and attain 
 their acme in old age. Pulmonary tuberculosis, with comparatively low rates 
 of morbidity and mortality in the first decade of life, rises sharply during the 
 second and third decades; its mortality, after maintaining high levels from 
 the thirtieth to the seventieth years, subsides in extreme old age. For all of 
 
GENERAL CONCLUSIONS 
 
 541 
 
 the other forms of tuberculosis taken together, the mortality is particularly 
 high in the first year and under age 5 and, having its highest point in the first 
 decade, runs on an even but relatively low level during the remainder of 
 life’s span. 
 
 From table 140 it will be noted that, in 1920, infectious processes were 
 responsible for 58 per cent of the total mortality under age 40 and for only 
 22 per cent of the mortality above this age-period. It is significant that for 
 pneumonia, tuberculosis, influenza, syphilis, and the pyogenic infections 
 (puerperal fever excluded), mortality was higher after than before age 40, 
 and that the reverse was true for dysentery, diarrhoea, typhoid fever, acute 
 articular rheumatism, and, as is to be expected, from the infectious diseases 
 peculiar to childhood. 
 
 The influence of race stock, as indicated by color, upon mortality from 
 some of the communicable diseases can be measured with some exactness. 
 According to tradition, the morbidity and mortality of the mosquito-borne 
 diseases was much less among negroes than among whites, but Buckler 
 recorded that in 1850 typhus fever, a disease comparatively new to this race, 
 was more common in the negro. The records show that of the acute intestinal 
 diseases, cholera (Buckler), typhoid fever, and diarrhoea (cholera infantum) 
 have been consistently more fatal to the negro than to the white. In 1850, 
 the mortality of epidemic dysentery, on the other hand, was four times greater 
 in whites than in negroes. 
 
 For the typically contactive diseases the comparison between the negro and 
 the white reveals interesting and significant results. The mortality from 
 small-pox, measles and influenza (except during the epidemic of 1918) has 
 been considerably higher in negroes. The converse is the case with scarlet fever. 
 In 1850, the mortality from this disease was one-third greater in whites than 
 in negroes, and during the past 15 years the rate w^as nearly three times 
 greater in the white than in the negro race. It is notable that while for both 
 measles and scarlet fever the morbidity-rates were higher in whites, the case- 
 fatality rates were higher in negroes; in other words the negro, though less 
 liable to attack, is more apt to die when attacked than is the white. For 
 whooping-cough the recorded morbidity has been considerably greater among 
 whites than among negroes, but the disease was four times more fatal for the 
 latter. This means that in respect to this disease the negro is less susceptible 
 to attack, but when he does contract it he is less resistant to its lethal force 
 than the white. In 1850, the mortality from diphtheria (membranous croup) 
 was about equal in the two races, but since 1905, at least, the mortality has 
 been twice as great among whites as among negroes. In recent years the mor¬ 
 bidity-rates have been consistently much higher in the white race. 
 
 For both lobar and broncho-pneumonia, since 1875 at least, the mortality- 
 rates have been markedly higher in the negro, and the same holds true for 
 morbidity-rates in 1921. Similarly for tuberculosis, both pulmonary and 
 other forms, the mortality-rates for negroes have been consistently and 
 markedly higher than for whites. There was no appreciable difference in 
 mortality for the two races from epidemic meningitis, but both morbidity- and 
 mortality-rates from poliomyelitis in negroes were double those obtaining in 
 whites in the epidemic year, 1916. In 1920, the mortality from tetanus was 
 somewhat higher and that from erysipelas was somewhat lower in negroes 
 
542 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 Table 140 .—Comparison of rates of death per 100,000 living population at all ages, 0 to 39 
 years, and J+0 years and over, from all causes and from certain groups of causes, and the 
 ratios per cent of mortality from the same in these age-groups for 1920. 
 
 
 At all ages* 
 
 0 to 3D years. 
 
 40 years and over. 
 
 
 
 
 o 
 
 S a 
 
 
 
 «♦-« 
 
 O 
 
 t-i 
 
 •2ft 
 
 
 
 O 
 
 2a 
 
 Causes of death. 
 
 
 
 -M 
 
 £ 
 
 3 
 
 c 2 
 
 
 
 4-> 
 
 £ 
 
 3 
 
 «2 
 
 
 
 -4-> 
 
 £ 
 
 3 
 c 2 
 
 
 
 
 o o 
 
 S to 
 
 o 
 
 
 V . 
 
 O <L> 
 
 S bo 
 
 0) 
 
 
 <0 . 
 
 O QJ 
 
 S b* 
 
 
 "S 
 
 
 U tj 
 a» 2 
 
 U % 
 
 <D 
 
 -4-> 
 
 a 
 
 
 * M 
 <L> 2 
 
 aj -C 
 
 a 
 
 
 
 , <1> 
 
 
 tf 
 
 
 CL 
 
 CL 
 
 « 
 
 
 CL u 
 
 a, 
 
 PC 
 
 
 CL u 
 
 CL*" 
 
 All nausea . 
 
 1548 
 
 
 
 
 994 
 
 
 
 
 2940 
 
 
 
 
 Group I. 
 
 
 
 
 
 
 
 
 
 
 Cancer . 
 
 Cardio-vascular-renal system in- 
 
 113 
 
 
 7.3 
 
 • • • • 
 
 15 
 
 
 1.5 
 
 • • • • 
 
 359 
 
 
 12 
 
 • • • • 
 
 eluding embolism and throm¬ 
 bosis . 
 
 471 
 
 
 30.4 
 
 • • • • 
 
 69 
 
 
 7.0 
 
 • • • • 
 
 1482 
 
 
 50 
 
 
 Cirrhosis of the liver. 
 
 Other diseases of liver and bil- 
 
 7' 
 
 
 • • • • 
 
 • • • • 
 
 1 
 
 
 • • • • 
 
 • • • • 
 
 24" 
 
 
 • • • • 
 
 
 iary system.. 
 
 8 
 
 
 • • • • 
 
 • • • • 
 
 3 
 
 
 • • • • 
 
 • • • • 
 
 19 
 
 
 • • • • 
 
 
 Diabetes . 
 
 Diseases of the stomach (cancer 
 
 21 
 
 
 • • • • 
 
 0 0 0 0 
 
 4 
 
 
 • • • • 
 
 • • • • 
 
 64 
 
 
 • • • • 
 
 
 excluded) . 
 
 7 
 
 
 • • • • 
 
 • • • • 
 
 5 
 
 
 • • • • 
 
 • • • • 
 
 13 
 
 
 • • • • 
 
 
 Hernia and intestinal obstruction 
 
 15 
 
 
 6.6 
 
 • • • • 
 
 9 
 
 
 3.8 
 
 • • • • 
 
 32 
 
 
 10 
 
 
 Genito-urinary system (Bright’s 
 
 • • • • 
 
 y 
 
 
 
 > 
 
 
 
 
 
 disease and tumor excluded) .. 
 Chronic diseases of the nervous 
 
 11 
 
 
 • • • • 
 
 • • • • 
 
 3 
 
 
 • • • • 
 
 • • • • 
 
 30 
 
 
 • • • • 
 
 
 system . 
 
 16 
 
 
 
 • • • • 
 
 7 
 
 
 
 • • • • 
 
 38 
 
 
 
 
 Leucaemia and anaemia . 
 
 7 
 
 
 
 • • • • 
 
 5 
 
 
 
 • • • • 
 
 14 
 
 
 
 
 Exophthalmic goitre . 
 
 2 
 
 
 
 • • • • 
 
 1 
 
 
 
 • • • • 
 
 4 
 
 
 
 
 Senility . 
 
 8 
 
 
 
 • • • • 
 
 
 1 
 
 
 • • • • 
 
 58 ^ 
 
 
 
 
 
 • • • • • 
 
 • 
 
 
 44.3 
 
 • • • • • 
 
 • 
 
 
 12.3 
 
 0 0 0 0 0 
 
 • 
 
 
 72 
 
 Group II. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Pneumonia (all forms) . 
 
 190 
 
 
 12.3 
 
 
 159 
 
 
 16.0 
 
 
 267 
 
 
 9 
 
 
 Tuberculosis (all forms) . 
 
 151 
 
 
 9.8 
 
 
 135 
 
 
 13.6 
 
 
 190 
 
 
 7 
 
 
 Whooping-cough . 
 
 8 ] 
 
 
 
 in 
 
 
 
 0 ] 
 
 
 
 
 Diphtheria . 
 
 14 
 
 
 • • • • 
 
 • • • • 
 
 19 
 
 
 • • • • 
 
 • • • • 
 
 0 
 
 
 • • • • 
 
 
 Measles . 
 
 7 
 
 
 • • • • 
 
 • • • • 
 
 9 
 
 
 • • • • 
 
 • • • • 
 
 0 
 
 
 • • • • 
 
 
 Scarlet fever . 
 
 2 
 
 
 6.6 
 
 
 3 
 
 >- 
 
 10.7 
 
 
 0 
 
 - 
 
 3 
 
 
 Influenza . 
 
 44 
 
 
 • • • • 
 
 • • • • 
 
 41 
 
 
 • • • • 
 
 • • • • 
 
 52 
 
 
 • • • • 
 
 
 Syphilis . 
 
 22 
 
 
 
 
 18 
 
 
 
 
 32 
 
 
 
 
 Acute articular rheumatism.... 
 
 5. 
 
 
 • • • • 
 
 .... 
 
 6 J 
 
 
 • • • • 
 
 • • • • 
 
 5 „ 
 
 
 • • • • 
 
 
 Typhoid fever . 
 
 5' 
 
 
 
 
 51 
 
 
 
 
 4") 
 
 
 
 
 Dysentery .'. 
 
 3 
 
 
 
 
 3 
 
 
 14.7 
 
 
 2 
 
 
 
 
 
 
 
 7 9 
 
 
 
 >- 
 
 * * * * 
 
 
 
 1 
 
 
 Diarrhoea (including cholera in- 
 
 
 > 
 
 
 
 
 
 
 
 X 
 
 
 fantum) . 
 
 105 
 
 
 
 
 139 
 
 
 
 
 19 
 
 
 
 
 Appendicitis . 
 
 131 
 
 
 
 
 15f 
 
 
 
 
 8' 
 
 
 
 
 Wound and all other infections 
 due to pyogenic bacteria, 
 
 • • • • 
 
 y 
 
 2.0 
 
 
 >- 
 
 3.0 
 
 
 >» 
 
 1 
 
 
 puerperal fever excepted... 
 
 17J 
 
 
 • • • • 
 
 • • • • 
 
 14J 
 
 
 • • • • 
 
 • •00 
 
 23 J 
 
 
 • • • • 
 
 • • • • 
 
 
 • • • • • 
 
 • 
 
 • • • • 
 
 37.9 
 
 • • • • • 
 
 • 
 
 • • • • 
 
 58 
 
 0 0 • 0 0 
 
 0 
 
 • • • • 
 
 22 
 
 Group III. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Puerperal state . 
 
 Affections peculiar to infancy 
 
 18 
 
 
 1 
 
 • • • • 
 
 24 
 
 
 2.4 
 
 • • t • 
 
 8 
 
 
 0 0 0 0 
 
 • • • • 
 
 including congenital malfor¬ 
 mations . 
 
 117 
 
 
 7.5 
 
 • • • • 
 
 8.5 
 
 162 
 
 
 16.3 
 
 • • • • 
 
 18.7 
 
 0 
 
 
 • 000 
 
 • • • • 
 
 Group IV. 
 
 
 
 
 
 
 
 
 
 
 
 Violence . 
 
 88 
 
 
 5.7 
 
 5.7 
 
 68 
 
 
 6.8 
 
 6.8 
 
 139 
 
 
 4.7 
 
 4.7 
 
 Total . 
 
 
 
 95.4 
 
 
 
 
 98.8 
 
 
 
 
 98.7 
 
 
 
 
 
 
 
 
 
 
GENERAL CONCLUSIONS 
 
 543 
 
 than in whites. During the years for which separate accounts have been kept, 
 specific rates for puerperal fever were much higher in the negro than in the 
 white race. Unfortunately, there are no data available for measuring the 
 relative susceptibility to attack and death from the febrile diseases of the 
 various branches of the white race. 
 
 Sex has exerted a marked influence upon both morbidity and mortality of 
 the diseases under consideration, and for all of them for which suitable data 
 are available the rates have been usually higher among males than among 
 females. It is especially worthy of note that with the decline in the mortality 
 from pulmonary tuberculosis which began after 1880, in both the white and 
 the negro races the decline has been much more abrupt among females than 
 among males. 
 
 It is clear then that these three attributes of the population, age, race, and 
 sex, have affected profoundly the course of morbidity and mortality of the 
 febrile diseases in the 109 years under review, and that changes in the pro¬ 
 portional distribution of the population in these respects have influenced 
 their courses significantly. It is a matter of great interest that the negro has 
 proved to be less susceptible than the white to malaria, yellow fever, and 
 dysentery, among the nuisance diseases, and to diphtheria, scarlet fever, and 
 whooping-cough among the contactive diseases, and that during the last 70 
 years, in respect to the last three diseases, his resistance has increased relatively 
 and in a decided degree. Among the other diseases for which comparison may 
 be made over a long period, the advantage still lies with the white race in 
 diarrhoea, typhoid fever, tuberculosis, pneumonia, and measles. In addition 
 to these, the white has exhibited a higher degree of resistance to small-pox, 
 typhus fever, cholera, poliomyelitis, and the pyogenic infections in general. 
 
 In connection with the influence of age upon the mortality from the various 
 febrile diseases, it has been shown that in the declines in the crude rates 
 exhibited by certain of these affections over a long series of years considerable 
 allowance must be made for the known changes in the age distribution of the 
 population, in consequence of which the ratio of individuals of susceptible age 
 has declined or has increased. In this respect the rates from the diseases of 
 childhood have been affected favorably and those from pneumonia and pul¬ 
 monary tuberculosis unfavorably. 
 
 It will be profitable at this point to discuss briefly certain biological dif¬ 
 ferences which characterize the causal agents of the febrile diseases. 
 
 The micro-organisms causing the febrile diseases considered in this work 
 belong to three fairly well-defined groups, the obligate parasites, the faculta¬ 
 tive saprophytes, and the facultative parasites. The members of the first 
 group, composed of true and constant parasites which are apparently incapable 
 under natural conditions of prolonged existence and multiplication, except 
 in connection with and usually actually within the bodies of living beings— 
 man or the lower animals—are exemplified by the causal agents of malarial, 
 yellow and typhus fevers, whooping-cough, measles, small-pox, chicken-pox, 
 vacinnia, influenza, mumps, epidemic meningitis, poliomyelitis, tuberculosis, 
 syphilis and gonorrhoea, and lobar pneumonia. The causes of diphtheria and 
 of scarlet fever, under usual circumstances typical members of this group, 
 occasionally find conditions favorable for living and even for multiplying 
 without living bodies in milk, an animal product, and for this reason are not 
 
544 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 obligate parasites in the strictest sense. It is more than possible that other 
 members of this group— B. tuberculosis, to mention one—may also under 
 conditions met with in nature grow in milk or other substances containing 
 organic matter. The causal agents of malarial, yellow, and typhus fevers are 
 peculiar in the fact that they require certain definite insects as intermediate 
 hosts and inoculators. It is not unlikely that some among the other viruses 
 mentioned above have similar affinities. As is well-known, hydrophobia, 
 trypanosomiasis, and relapsing fever are caused by obligate parasites with 
 intermediary hosts. 
 
 Typical members of the second group are the micro-organisms causing the 
 acute intestinal diseases, cholera, dysentery, the diarrhoeas and typhoid fever, 
 all of which seem to retain their vitality in water and under favorable circum¬ 
 stances to be capable of multiplying, at temperatures below that of the human 
 body, in milk and in various other substances containing organic matter. 
 However, their normal habitat appears to be the human body, and especially 
 lesions of its alimentary tract, and they are rarely if ever found in the outside 
 world except under conditions indicating pollution with human excreta. 
 
 The representative micro-organisms of the third group are the pyogenic 
 bacteria, well-nigh ubiquitous in the outside world in soil, manure, night-soil, 
 and the like, whence they easily reach the exposed surfaces of the human body. 
 In order that they may invade the tissues and establish the condition of 
 infection, they commonly, but by no means invariably, require assistance in 
 the shape of surface wounds, destructive irritants, or some previous or con¬ 
 comitant infection. Such organisms as the pathogenic streptococci and staphy¬ 
 lococci, B. tetani, B. welchii, B. mucosus, and B. pyocyaneus, are to be 
 regarded as normally saprophytes. However, when well established as facula- 
 tive parasites, certain strains of staphylococci and streptococci often, and 
 other forms more rarely, develop marked aggressiveness and a peculiar toler¬ 
 ance for human tissues, and are not only readily transmissible by direct and 
 indirect contact, but cause local epidemics, of which erysipelas, puerperal fever, 
 umbilical-cord and other types of wound infection are familiar examples. 
 As secondary invaders, particularly in diseases caused by the organisms of 
 the first group, they are responsible for a long series of complications, and 
 are very effective determinants of mortality. This association is of peculiar 
 importance in connection with the exanthemata, in which the clinical course 
 may be greatly altered and the rate of fatality is often largely determined by 
 mixed infection with pyogenic bacteria. Whooping-cough, diphtheria, and 
 typhoid and typhus fevers are frequently similarly influenced. The causal 
 agents of these affections not only provide, by injury to certain surfaces of the 
 body, favorable points of attack for pyogenic bacteria, but, as has been proven 
 in the case of some of them, may actually lower the general resistance to these 
 secondary invaders. 
 
 It is evident that, in the usually accepted meaning of the terms, examples 
 of nuisance and contactive modes of spread are offered by members of all 
 three of these groups, but that the last two groups furnish on the whole the 
 best examples of the former mode of dispersion. Malarial, yellow, and typhus 
 fevers, classified from the standpoint of public-health administration as nui¬ 
 sance diseases, in view of the fact that they are directly inoculable to man by 
 
GENERAL CONCLUSIONS 
 
 545 
 
 means of a lower order of living things, must be regarded from the viewpoint 
 of the causal agents as very highly developed special cases of contact infection. 
 Indeed, they are the best known examples of their type of strictly contactively 
 spread infections, for with them it seems certain that all other means of 
 transmission are excluded. It is evident from practical observation that the 
 causal agents of the intestinal diseases can spread effectively from individual 
 to individual by direct contact alone, and in practice this method is often 
 apparently an important if not the chief reliance of the causes of bacillary 
 dysentery and infantile diarrhoea. The indirect method of transmission to 
 new hosts by foods, in which they can multiply, and by flies acting as mechani¬ 
 cal carriers, is for them a fortunate circumstance by which their opportunities 
 for transfer in effective dosage are greatly increased. It is clear from what 
 has been said that, generally speaking, the pyogenic infections are to be 
 regarded as primarily nuisance-borne, and that their causal agents are ubiqui¬ 
 tous in man’s environment. Often their action is more marked in symbiosis, 
 in which they have complicated the fight by killing their host. 
 
 It is to be recalled that healthy individuals, as well as convalescents and 
 the totally recovered, have been proved to harbor on the body-surfaces and to 
 be capable of disseminating certain members of each of these groups. Familiar 
 examples are B. diphtherice, meningococcus, pneumococcus, B. typhosus, B. 
 cholerce, streptococcus, staphylococcus, B. tetani, B. mucosus, and B. welchii. 
 Numerous observations seem to warrant the inference that similar conditions 
 obtain with regard to the unidentified causal agents of the exanthematous 
 diseases. Among the acute diseases caused by obligate parasites and by faculta¬ 
 tive saprophytes, the carrier state, in or on the bodies of both individuals who 
 have recovered and of those who have not themselves been successfully attacked, 
 is, in the light of present knowledge, to be regarded as the last resort for sur¬ 
 vival of their causal agents, and whence new hosts may be invaded when 
 conditions become favorable. Thus only can revival of incidence after seasonal 
 subsidence be adequately explained. For those of these agents upon which 
 experiment can be tried, prolonged exposure, either to direct sunlight or to 
 drying, or to low temperatures, has proved fatal. The facts at hand seem to 
 indicate that the possibilities of indefinite preservation of these species of 
 causal agents in the outside world are minimal. 
 
 For the obligate parasites certainly, and for the facultative saprophytes prob¬ 
 ably, invasion of new hosts must be regarded as necessary for a complete or 
 rounded life and therefore actual parasiticism may be said to be a necessity 
 for the members of the first two groups and a luxury for the third group. 
 In this sense true parasiticism implies as a normal condition of existence 
 multiplication within or at the expense of the tissues of a living host rather 
 than on a body-surface at the expense of excrementitious matter. 
 
 Analysis of the Baltimore material emphasizes the paramount influence of 
 season upon the incidence of diseases caused by the parasitic micro-organisms, 
 and the evidence at hand indicates that these seasonal variations of incidence, 
 and consequently of mortality, on the whole, are concerned more intimately 
 with the natural history of the parasites than with changes in the relative 
 resistance of their hosts. The spread of the parasites of malaria and yellow 
 fever was naturally restricted to the mosquito season, i. e., to the warm months 
 
546 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 of the year. Typhus fever occurred at all seasons, but its greatest prevalence 
 was in winter and spring. The intestinal diseases, spread chiefly by foods, 
 especially water and milk, w r ere most prevalent in the warm months, partly, 
 at least, because conditions of temperature are then most favorable for the 
 survival and multiplication of their causal agents in these media when infected, 
 and when carrier flies are active. 
 
 The exanthematous diseases and pneumonia sank almost invariably to low 
 levels in warm weather, gradually increased in activity in the fall, and attained 
 their highest incidence in the winter and spring. Diphtheria, also of low inci¬ 
 dence in summer, increased rapidly in prevalence in the early fall, soon reached 
 a high level as the weather cooled, and, usually attaining its acme in Decem¬ 
 ber and January, gradually subsided during spring. The course of pneumonia 
 was much the same, except that the fall rise was less abrupt and the peak was 
 attained rather later in the winter. The monthly annual morbidity and mor¬ 
 tality of pulmonary tuberculosis followed the seasons in a similar manner. 
 With whooping-cough, while the recorded incidence was about equally divided 
 between warm and cold months, mortality was decidedly higher during the 
 former. The incidence and mortality of epidemic meningitis was confined to 
 the late winter, the spring, and the early summer. While sporadic cases, 
 usually fatal, of poliomyelitis occurred in winter and spring, the chief out¬ 
 breaks of this disease have been confined to late summer and early fall. 
 
 These facts suggest very strongly that the causal agents of such of these 
 diseases as are transmitted from person to person chiefly by direct contact, 
 such as the exanthemata, whooping-cough, diphtheria, pneumonia, and tubercu¬ 
 losis, pass through alternating phases of invasive or aggressive capacity which 
 are in some intimate manner determined by meteorological phenomena, and 
 that of these temperature is the predominant factor. In this connection it is 
 not necessary to assume the existence on the part of these organisms of com¬ 
 plicated life-cycles such as characterize certain protozoa. Cool or cold weather 
 or some accompanying physical state or states may act simply as stimulants 
 to drive them to the cover of the tissues of appropriate hosts. As has already 
 been pointed out, adequate explanation of the influence of temperature in 
 general upon the prevalence of the nuisance diseases is found in its determin¬ 
 ing influence upon environmental conditions which favor the multiplication or 
 the special modes of spread of their causal agents. However, for the intestinal 
 diseases, except cholera, whose cause can not survive cold, warm weather must 
 be regarded as only an adjuvant and not a necessity, for large outbreaks, in the 
 case of sudden and massive pollution of drinking-water, may occur in cold 
 weather. 
 
 The contrary behavior of epidemic meningitis and of poliomyelitis, as com¬ 
 pared with the exanthematous and the respiratory diseases, makes necessary 
 the assumption that the aggressiveness of their causal agents is stimulated 
 by factors associated with hot rather than with cold weather, or that their 
 multiplication and their spread to individuals is determined by some other 
 environmental factors, including perhaps intermediate hosts. It is significant 
 that for the typical contactive diseases it is not the degree of cold or of heat, 
 but the change from warm to less warm atmosphere with which rise in invasion 
 rate is associated, and the suspicion remains that after all the result is bound 
 
GENERAL CONCLUSIONS 
 
 547 
 
 up with season rather than with temperature changes that accompany the 
 seasons. This material furnishes no data concerning the seasonal and other 
 external relationships which may influence the invasive capacity of the widely 
 different organisms causing the three great contactive venereal diseases, gonor¬ 
 rhoea, syphilis, and chancroid. In regard to the facultative parasites, it is 
 significant that the pyogenic cocci when well established as parasites are appar¬ 
 ently more active in cold than in warm weather. Familiar examples of this 
 phenomenon are tonsillitis, broncho-pneumonia, and erysipelas. 
 
 In their struggle for existence and the preservation of their position in the 
 cosmic order, it is evident that among other requirements for the strictly 
 parasitic micro-organisms causing the diseases under discussion, two are of 
 paramount importance; resistance to the protective powers of their hosts and 
 escape from the lesions to the free surfaces of the body, whence new hosts may 
 be invaded. The interplay of forces involved in the first constitutes an impor¬ 
 tant part of the large field of immunity, a subject which can not be considered 
 exhaustively here. In regard to the second, it will suffice to indicate that for 
 each of the parasites of the nuisance and of the contactive diseases here con¬ 
 sidered, this point is in the main well covered. To recall a few examples, the 
 parasites of the insect-borne diseases have developed the elaborate system of 
 intermediary hosts, and for nearly all of the rest ample opportunity is given 
 for escape to body-surfaces, often by means of superficial lesions, as, for 
 instance, by the sputum in pneumonia and pulmonary tuberculosis, the skin 
 or the mucosas for the exanthematous diseases, the intestinal ulcers of typhoid 
 fever, the skin in erysipelas. With others, of which whooping-cough, diph¬ 
 theria, cholera, dysentery, and diarrhoea are familiar examples, the essential 
 lesions are superficial and exit to new hosts by direct or indirect means is easy. 
 Tuberculosis, syphilis, and gonococcal and pyogenic infections often furnish 
 examples of inclosure of the specific parasites in lesions of the internal organs 
 from which escape is shut off, whether the host lives or dies, as in tuberculous 
 meningitis, syphilitic myocarditis, gonococcal and streptococcal endocarditis. 
 
 In considering the natural history of the transmissible diseases, it has 
 become customary to view them entirely from the standpoint of the host, and 
 to overlook the important fact that it is invasive and not lethal capacity that, 
 biologically speaking, suits the best interest of their parasites. It is self- 
 evident that, among the diseases caused by obligatory parasites and facultative 
 saprophytes, death of the host is inimical to the propagation of the parasite 
 species, and that the shorter the period between invasion and the occurrence of 
 death the less the opportunity for development, multiplication, and escape of 
 the parasites. From the standpoint of the parasite species the death of the host 
 is not a triumph, but a calamity. For the satisfactory development of a strain 
 of tubercle bacilli, for instance, it is much more advantageous that the host 
 should survive for years, with ulcerative pulmonary tuberculosis, than die in 
 a few weeks of phthisis florid a. The causal agents of scarlet fever and measles 
 are much more safely intrenched at the present time with their high morbidity 
 and low mortality rates than was the case either before these diseases became 
 endemically established or in later years, when the mortality was excessively 
 high and the morbidity relatively low. Diphtheria antitoxin, by preserving 
 the life of those attacked and thus favoring the carrier state, has been perhaps 
 
548 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 as great a boon to the diphtheria bacillus as to the human species. It is clear, 
 therefore, that all methods and means, whether they entail active or passive 
 immunity or medical care, or even curative treatment with specifics, which 
 delay death or which establish recovery, if not attended by destruction or 
 encapsulation of the parasites in infected hosts, favor the propagation of the 
 invading organisms at the expense of possible new hosts. 
 
 It has been pointed out in previous chapters that after long endemic establish¬ 
 ment certain of the acute parasitic diseases which have become characterized 
 for years by low morbidity and high mortality have exhibited marked gains 
 in invasive capacity with the loss of lethal force. Clear-cut examples of this 
 phenomenon are furnished by the courses of measles, scarlet fever, whooping- 
 cough, and diphtheria. In this case it is evident that the result may be affected 
 by changes in the constitutional attributes of both the population and the para¬ 
 sites. Since in these particular diseases both attacks and deaths are confined 
 so largely to early youth, the period of life before procreation is possible, high 
 case-fatality rates must tend in time to diminish in the population the pro¬ 
 portion of individuals with feeble natural resistance to lethal issue; so that 
 by a process of natural selection, towards the end of the period under review, 
 those diseases whose causal agents are obligate parasites have as their material 
 for attack a population descended from ancestors, ( a ) who resisted attack 
 after exposure, (5) who were not exposed at all, or (c) who, though succumb¬ 
 ing to attack, were able to escape death. From the standpoint of the parasites, 
 natural selection must tend in the long run to favor the persistence of strains 
 of low as opposed to those of high virulence, for the latter by killing their 
 hosts limit their own opportunities to spread, and strains of lower lethal force 
 must have much greater chances for propagation and transmission to suc¬ 
 cessions of new hosts. 
 
 Diphtheria will serve as an example to illustrate these points. The record 
 shows that the mortality of this disease, from at least as early as 1812 to 
 about 1860, ran at a fairly constant and relatively low level. It is attested by 
 an accurate observer (56) that as membranous croup, the type prevalent during 
 this period and characterized by a very high case-fatality rate (90 per cent), 
 it did not spread readily from the sick to the well in households and neighbor¬ 
 hoods. In other words, while the case-fatality rate was nearly 100 per cent, 
 both the morbidity and the mortality-rates among those of susceptible age 
 were comparatively low. Suddenly, in association with a pandemic, when new 
 strains of the causal agent were imported, both morbidity and mortality-rates 
 from the previously prevalent laryngeal and the new naso-pha,ryngeal types 
 rose enormously and remained at high levels for over 25 years. Thus, coinci¬ 
 dentally with the presence in the population of a large proportion of children 
 sprung in part from parents who had resisted the disease, mortality declined 
 by 1890 to near its previous level. With the introduction of intubation and 
 of antitoxin for both cure and prevention, the adoption of compulsory isola¬ 
 tion controlled elaborately by the culture test, morbidity has actually increased 
 in the face of a remarkable decline in mortality and in case-fatality rates. 
 Without these means and methods of artificial interference, similar but even 
 more marked changes occurred in these rates for measles, scarlet fever, and 
 whooping-cough. These characteristics are in striking contrast to the behavior 
 
GENERAL CONCLUSIONS 
 
 549 
 
 of certain other diseases, such as pneumonia, typhoid fever, and pulmonary 
 tuberculosis, which are not confined to the lower age-groups of the population 
 and in which the duration of the illness is on the whole rather longer and the 
 case-fatality rate is on the whole lower than in the group of affections just 
 discussed. 
 
 However, such explanations of the observed phenomena can not be con¬ 
 sidered entirely satisfactory. It is not improbable that, in consequence of 
 consecutive passage through generations of individuals upon whom increased 
 resistance has been conferred by the above-discussed form of natural selection, 
 the causal agents of many of these diseases have undergone actual as well as 
 relative decrease in lethal force. A third alternative is the assumption that 
 among the progeny of single organisms or of groups of organisms there should 
 occur as a normal condition several or even many strains differing among 
 themselves in respect of invasive and lethal capacities. In this case the increase 
 or decrease in either one or both of these attributes occurring in connection 
 with a particular disease, when endemically established, may be considered as 
 being due to a chance or even to a cyclic predominance of these respective 
 characters to an unusual degree. Similarly, the subsidence almost invariably 
 observed in respect of one or both of these qualities within a comparatively 
 short time, even when no restrictive interferences are interpolated, may be 
 associated with the return in the mass of the prevalent strains to their previous 
 state. 
 
 Lastly, it is possible that increases and decreases in invasive and in lethal 
 force on the part of the obligate parasites may be due at some times to definite 
 mutations in the sense of DeVries and at other times to the becoming domi¬ 
 nant of characters long latent. Some such hypothesis is almost necessary for 
 the explanation of such sudden and great changes in these respects as occur 
 in the life-history of parasites at the time of great pandemics. Nor otherwise 
 does it seem possible to explain the repeated declines and complete disappear¬ 
 ance from the city of scarlet fever, measles, influenza, and typhus fever, after 
 epidemic outbreaks and in the absence of any measures of control, and of 
 small-pox under the same conditions, except imperfect vaccination. In the 
 solution of these many and complex phenomena more than one formula seems 
 necessary. 
 
 One set of parasites by determining the death of hosts is often inimical to 
 another. While the parasites of most of the typical specific diseases do not as 
 a general rule invade the same host at the same time, their hosts are often 
 attacked by facultative parasites, particularly the streptococci and staphylococci, 
 and frequently with fatal results. Familiar examples are furnished by the 
 exanthemata, diphtheria, whooping-cough, typhoid fever, and pulmonary 
 tuberculosis. The coincidence of epidemics of a disease caused by an obligate 
 parasite with one caused by a facultative parasite may be associated with the 
 augmentation of the lethal force of both. Illustrative instances are furnished 
 in the simultaneous occurrence of epidemics of scarlet fever and of erysipelas, 
 and of influenza and of streptococcus pneumonia. Similarly, the occurrence 
 of an epidemic of a disease caused by an obligatory parasite may increase the 
 case-fatality rate of another disease of the same class or of one due to a faculta¬ 
 tive saprophyte. Striking examples of this interaction are afforded by the 
 
550 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 influence of the influenza of 1918 upon the case-fatality rates of whooping- 
 cough and of typhoid fever in Baltimore. The simultaneous occurrence in the 
 same individual of two or more diseases caused by obligate parasites is, how¬ 
 ever, not unknown; the subjects of the venereal diseases and of tuberculosis 
 are apparently at least as vulnerable to other infections of this class as are the 
 healthy, and syphilis, gonorrhoea, and chancroid often coexist in the same 
 person. While the curious quality possessed by vaccinia and variola of 
 almost completely immunizing against each other is without parallel among 
 diseases, it is quite possible that antagonisms similar in kind though less 
 marked in degree may exist between other febrile diseases. In this connection 
 it is of interest to recall that the declines in the mortality from pulmonary 
 tuberculosis following influenza epidemics in Baltimore and especially the fall 
 in its recorded morbidity-rate since 1918 suggest very strongly that, contrary to 
 generally accepted medical opinion, non-fatal attacks of influenza may actually 
 protect, to some degree at least, against either incidence or fatality, or both, 
 on the part of tuberculosis. The significant and sustained recessions in mor¬ 
 bidity and mortality from pulmonary tuberculosis since the influenza epidemic 
 of 1918 may well be causally associated with the circumstance that in this 
 epidemic the incidence of the disease was unusually heavy in young adult¬ 
 hood and in mid-age, the very age-groups in which the sharpest declines in 
 mortality are known to have occurred (graph 25). To limit the observed 
 relation between this influenza epidemic and the subsequent decline in the 
 incidence and mortality of tuberculosis to a supposed weeding-out effect of 
 the former upon tuberculosis susceptibles in the population is unwarranted by 
 actual conditions; these declines have been too great and too lasting to be 
 accounted for by this factor alone and since 1918, with continuous sharp 
 recessions in the rates of tuberculosis morbidity and mortality, endemic influ¬ 
 enza has remained on a high level of incidence with a comparatively low case 
 fatality rate. 
 
 Paradoxical as it may seem and abhorrent to current opinion as it is, from 
 the standpoint of the parasite the ideal condition of existence is characterized 
 by ready infections of new hosts with minimal mortality among the victims. 
 And, evidently from the standpoint of the host population, with those diseases 
 against whose parasites science and art have no methods either of extermina¬ 
 tion or of control, with which, in short, the symbiosis defies artificial control, 
 this is the most satisfactory arrangement. After a long interplay of their 
 respective forces, this condition has been attained between the Baltimore 
 population and such diseases as measles, scarlet fever, chicken-pox, and 
 mumps. Whooping-cough and tuberculosis show indications of the same 
 course. Diphtheria has been influenced in the same direction by natural forces 
 assisted by antitoxin. It is conceivable that, other things remaining equal, by 
 natural methods in the course of time one or more of these diseases may 
 gradually lose its identity and disappear. On the other hand, any one of them 
 may, in the future as in the past, suddenly change its attributes in respect of 
 invasiveness and lethality. 
 
 For man, preventative inoculation of natural or of attenuated living or of 
 killed viruses or of their products has been widely used for both prevention and 
 cure. For the latter purpose (with a few exceptions, in connection with some 
 of the facultative parasites, such as staphylococci), the practice has been 
 
GENERAL CONCLUSIONS 
 
 551 
 
 barren of results, and therefore exerts no influence upon spread of these 
 diseases. Inoculation for prevention, while successful in some instances, has, 
 all things considered, proved to be by no means a perfect means of interference 
 with the propagation of parasites by transmission from old to new hosts. 
 Inoculation with natural small-pox virus, by producing a milder type of the 
 disease, was eminently successful in reducing the mortality-rate, but as mor¬ 
 bidity "was raised to the maximum, from the standpoint of the causal agent 
 conditions were well-nigh ideal. The highest degree of perfection in restraint 
 of spread of a disease by inoculation of a living virus is attained by Pasteur's 
 method of inoculating against rabies. The secret here lies in the production 
 after the inoculation of an attenuated living virus of an active immunity 
 during the normal incubation period of rabies, i. e., between infection and the 
 efflorescence of the disease. Vaccination against small-pox is a case of sub¬ 
 stitution of one disease, a mild one, for another disease, which is ordinarily 
 severe. Here the development of small-pox is not always permanently pre¬ 
 vented in an individual by a single successful attack of vaccinia any more 
 than is the case with small-pox itself, whether naturally or artificially acquired. 
 However, by judicious repetition of vaccination perfect protection commonly 
 is attained. 
 
 On a much lower plane of value in this connection ranks inoculation with 
 the causal agents of certain bacterial diseases or their poisonous products, 
 the former attenuated or even killed and the latter reduced in power by physi¬ 
 cal or chemical means. The best known examples which have proven successful 
 in man are tuberculosis, plague, cholera, typhoid and para-typhoid fevers, 
 dysentery, staphylococcus infection, and diphtheria. In tuberculosis, the first 
 of these in chronological order, the method has at least a very restricted field 
 of usefulness. In diphtheria, the last of these diseases for which preventive 
 inoculation with the poisonous products of its causal agent (toxin with anti¬ 
 toxin) has been tried, the results are promising. For the rest, while these 
 measures are often of service for short periods of time in emergencies, and 
 especially among readily controlled groups of individuals, as in armies, on 
 ships, and in institutions, they commonly fail in the long run to displace 
 permanently the parasites in ordinary populations; the protective immunity 
 is usually transient and of such a nature that growth of certain of these para¬ 
 sites on the body-surfaces is not seriously interfered with. 
 
 It has been made clear that curative sera, both antitoxic and antimicrobic, 
 in so far as they may delay or completely inhibit a fatal issue without wholly 
 destroying the parasites (and none accomplish this to a greater degree than 
 occurs under natural conditions), must, other conditions remaining equal, favor 
 rather than restrict the spread of the respective diseases from old to new 
 hosts. Finally, in regard to the whole list of the “ febrile ” diseases, it follows 
 as a logical necessity that any other modes of curative treatment and all modes 
 of natural recovery which are not associated with the complete sterilization 
 of the causal agents in or on the body, or which do not result in their perma¬ 
 nent encapsulation in the infected tissues, must favor the propagation of the 
 parasites and their extension to new hosts. It follows further that, except 
 where man has been able to invent methods that accomplish these ends or 
 that break down all means of communication through which infection is 
 36 
 
PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 brought about, there is no reasonable hope that diseases of this class may be 
 curbed, much less eradicated. 
 
 In Baltimore, in one way or another and in halting fashion, after a struggle 
 lasting 123 years, man has been able to stamp out some of the nuisance diseases 
 (malaria and yellow fever), to materially interfere with the prevalence and 
 mortality of others (the acute intestinal affections), and one (typhus fever) 
 has well-nigh dropped out without his interference. Of the affections seem¬ 
 ingly spread chiefly by personal contact, one (small-pox) is held in check 
 temporarily by substitution, the mortality of one (diphtheria) has been 
 decidedly reduced by medical treatment (intubation and antitoxin), one 
 (syphilis) has probably been lowered in both morbidity and mortality by 
 specific medication, and several (the pyogenic infections) have been curbed in 
 both incidence and mortality to a considerable though not measurable degree 
 by antisepsis. The incidence and mortality of one member (tetanus) of this 
 latter group have been modified by administrative acts and specific antitoxin. 
 It will be observed that for this group of contactive diseases practically all 
 of the changes in incidence and in mortality were brought about by measures 
 that are typically medical and applied for the most part at least by private 
 physicians in the routine care of their patients. Even vaccination, though 
 for many years required by law, is and has been, except in a few notable 
 instances, carried out mainly by private physicians. For the rest of the impor¬ 
 tant diseases of this class, including pulmonary tuberculosis, pneumonia, 
 measles, scarlet fever, influenza, whooping-cough, epidemic meningitis, and 
 poliomyelitis, the struggle continues to be one in natural selection between the 
 causal agents and the host population, and barely, if at all, modified by certain 
 medical or administrative interferences. 
 
 Such gains over the nuisance diseases as have been attained through admin¬ 
 istrative measures were either complete or well on their way under the influ¬ 
 ence of theories long exploded. The sequel has proved that the early Balti¬ 
 moreans were wise in confining their attention to the nuisance diseases and to 
 small-pox, but unwise in not dealing more expeditiously and thoroughly than 
 they did with the conditions which favor their spread. 
 
 AFFECTIONS PECULIAR TO CHILD-BIRTH AND TO EARLY INFANCY. 
 
 The evidence at hand indicates that the maternal death-rate from causes 
 connected with child-birth has always been high in Baltimore. The course of 
 the crude rates for this group of causes suggests that the wide fluctuations in 
 the rates which occurred at certain periods of the nineteenth century were 
 due in the main, at least, to exacerbations and recessions in the death-rate 
 from puerperal fever. It would appear that until after 1900 the rate from 
 all other causes in the puerperal state ran a fairly constant course on a very 
 high level. Since 1900 the mortality from puerperal fever has declined consid¬ 
 erably, and there has been some fall in the rates from other causes. During 
 the 6-year period 1915-1920, the maternal child-bed death-rate has averaged 
 about 65 per 10,000 births, and something like 30 per cent of this was due to 
 puerperal fever. The risk rate of death from causes connected with child¬ 
 birth were nearly twice as great in the negress as in the white woman, and 
 from puerperal fever the mortality in the former is more than double. In 
 
GENERAL CONCLUSIONS 
 
 553 
 
 spite of the fact that for 25 years a large proportion of the deliveries have 
 occurred under the auspices of well-conducted obstetrical clinics, the maternal 
 death-rate from causes connected with child-birth continues to be notoriously 
 high. It appears that this state of affairs is only in part due to the obstetrical 
 activities of untrained midwives. 
 
 The group of affections responsible for such high mortality in early infancy 
 demands consideration here. Owing to lack of specific knowledge, these affec¬ 
 tions can not be delimited with sharpness into the organic or constitutional 
 and the infectious, and the determination in respect of the primary cause of 
 death as between these two categories of causes is even more difficult than in 
 old age. Pathological anatomists as well as clinicians are impressed with the 
 difficulty in determining the actual cause of death in a large proportion of 
 infants coming to autopsy. Even with those gross malformations evidently 
 incompatible with independent life, it is not ascertained what, if any, causal 
 role is played by infection. To what degree deaths of seemingly well con¬ 
 structed and developed infants are due to underdevelopment, or hypoplasia, 
 of important organs of assimilation, metabolism and regulation, and in what 
 manner such hypothetical deficiencies are caused by inter-uterine infection, are 
 questions which are shrouded in mystery. That congenital infections, especially 
 syphilis, are common antecedents and concomitants of still-birth and of 
 death within a few days after birth of apparently well-developed infants is 
 well established. Williams attributed to congenital syphilis one-fourth of the 
 deaths among a large series of such cases in his service at the Johns Hopkins 
 Hospital. 
 
 The high percentage of still-births to total births (6 among whites and 13 
 among negroes), in 1919 and 1920, indicates that the causes of fetal mor¬ 
 tality, whether concerned with infections, with constitutional defects, or with 
 poor obstetrical care, continue to act with unusual force. That post-natal 
 infections are responsible in part for the high mortality among the newly- 
 born is attested by the high death-rate from tetanus neonatorum that obtained 
 only recently in Baltimore. It is not unlikely that many deaths of young 
 infants are still due to general infections with pyogenic bacteria following 
 improper care of the umbilical cord. 
 
 It has been shown that, as measured by crude rates and by rates based 
 upon the enumerated populations under 1 year of age for the census years, 
 the mortality from affections of early infancy (Chapter XVIII) was not 
 only extraordinarily high, but ran on a fairly constant level from 1830 to 
 1900, and after the latter date underwent a sharp decline. The rates specific 
 for age fell from 11,029 in 1900 to 5,871 in 1920. Bates calculated upon the 
 number of reported live-births declined from 5,207 in 1915 to 4,578 in 1920. 
 In the latter year the mortality from this group of affections comprised 43 
 per cent of the total mortality in the first year, and 84 per cent of this fell 
 within the first month of life. The mortality rates per 100,000 for the respec¬ 
 tive rubrics of this group of causes, in white and in negro infants in 1920, 
 calculated on the basis of the reported births, are given in table 141. 
 
 The rates for negroes was conspicuously higher in each rubric, but in only 
 one—congenital debility—was the rate significantly greater in proportion to 
 the whole. Congenital malformations were responsible for a higher propor- 
 
554 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 tion of the total mortality in whites than in negroes. For the two remaining 
 rubrics the proportional distribution of mortality was the same in two races. 
 It is significant that from not only causes acting in utero and at birth (still¬ 
 births), but from those operative most conspicuously during the first month 
 of extra-uterine life, the negro is a much poorer risk than the white. That 
 this is due largely to causes inherent in race stock is supported by the fact 
 that in a very much larger proportion of instances than the white the negro 
 infant has the advantage of care before, during, and immediately after birth, 
 by the two university obstetric clinics. 
 
 While congenital syphilis, gonorrhoea, tetanus, and erysipelas were credited 
 with rates of 138, 11, 21, and 43, respectively, or about 15 per cent of the 
 total mortality during the first year of life, only 40 per cent of the mortality 
 from these four diseases was recorded as falling within the first month of life, 
 
 Table 141. 
 
 
 White. 
 
 Negro. 
 
 
 Rate. 
 
 P. c. of 
 mortality. 
 
 Rate. 
 
 P. c. of 
 mortality. 
 
 Congenital malformations . 
 
 929 
 
 22 
 
 1156 
 
 19 
 
 Congenital debility, etc. 
 
 2473 
 
 58 
 
 4066 
 
 63 
 
 Other diseases peculiar to infants.... 
 
 765 
 
 18 
 
 1185 
 
 18 
 
 Convulsions of infants. 
 
 63 
 
 1.5 
 
 105 
 
 1.6 
 
 Total . 
 
 4237 
 
 99.5 
 
 6518 
 
 99.6 
 
 where the bulk of their influence would be expected to be felt. The inference 
 is clear that many deaths from congenital syphilis and from pyogenic infec¬ 
 tions occurring at and immediately after birth must be hidden under the 
 rubrics for congenital debility and “ other diseases peculiar to infants.” In 
 the first month of life the proportional distribution of the mortality from 
 the other groups of diseases responsible for deaths in the first year as expressed 
 in percentages of the whole, were: for diarrhoea 6, acute diseases of the 
 respiratory system 8, and measles 8. Scarlet fever, influenza, and meningitis 
 caused no deaths in this age-period. 
 
 The evidence at hand indicates that the gradual but very considerable 
 decline in the rate of mortality from affections of early infancy which has 
 occurred since the opening of the twentieth century has been associated with 
 a number of factors. Among the most important of these are the proportional 
 increase in the community of mothers of race stocks among whom breast¬ 
 feeding of infants is customary, the expansion of the activities of obstetric 
 and pediatric clinics, and the development of welfare clinics for the super¬ 
 vision of the care and feeding of infants. 
 
 VIOLENCE. 
 
 Both of the two classes of violence, the intentional (suicide and homicides) 
 and the unintentional (accidental) have been conspicuous causes of death 
 in Baltimore for over 100 years. While the rates for all forms of violence have 
 fluctuated within considerable limits during this time, on the whole there was 
 
GENERAL CONCLUSIONS 
 
 555 
 
 a decrease of 5.5 per cent. The mortality from intentional violence increased 
 by 100 per cent between 1812 and 1920, and that from accidental causes 
 decreased by 20 per cent. Drowning, the major cause of accidental death in 
 the early history of the city, declined in importance in this respect by 1850. 
 Since 1880, largely on account of the increase in steam and electric railroads 
 and in more recent years of automobiles, the mortality from this cause of 
 death has risen steadily. Industrial accidents are, in ordinary times, relatively 
 unimportant causes of death in Baltimore. As deaths from falls incident to 
 the infirmities of old age are classified under accidents, the survival during 
 the past 50 years of a steadily increasing proportion of the population to old 
 age has unfavorably influenced the rate for unintentional violence. 
 
 THE CHRONIC ORGANIC DISEASES. 
 
 In connection with the chronic organic or degenerative diseases, several 
 facts of far-reaching importance stand out very clearly. The most striking 
 of these facts disclosed by the various tables analyzed in previous chapters 
 may be summarized as follows: The mortality ascribed to affections of this 
 category is not only confined very largely to age-period 40 years and over, but, 
 as a rule, increases progressively and markedly in this age-group from decade 
 to decade into old age. The cardio-vascular-renal system is of all others the 
 one most frequently the seat of chronic non-cancerous degenerative diseases 
 causing death, and in this respect surpasses all the other organs of the body 
 taken together. This is the only organ-system (or organ, the pancreas as 
 judged by diabetes, excepted) for which mortality-rates from affections of 
 this character, when corrected for age, have advanced conspicuously during 
 the last 40 or 50 years. Cancer of the cardio-vascular-renal system is relatively 
 rare. During the last 20 or 30 years the mortality from cancer of the breast 
 and the uterus (and ovaries) has declined in association with improvement 
 in early diagnosis and in surgical measures, and when allowances are made 
 for improvement in diagnosis and in statistical classification, for deaths in 
 non-residents, and for changes in the age, sex, and race distributions of 
 the population, it is doubtful if the mortality from cancer has increased 
 significantly. 
 
 Since age exerts the controlling influence upon the lethal force of cancer 
 and of the various non-cancerous chronic organic diseases, light will be shed 
 upon the present discussion by a comparison of the relative values of different 
 causes of death in age-periods 0 to 39 years and 40 years and over for the 
 census year 1920. In table 140 the rates of mortality, for all ages and specific 
 for those two age-periods, from all the main causes of death are arranged in 
 four fairly well defined groups: (1) cancer of all organs and the non- 
 cancerous chronic degenerative affections of various organs and organ sys¬ 
 tems; (2) the definitely known infectious diseases; (3) affections of the 
 puerperal and early infantile states; (4) violence. A few comparatively unim¬ 
 portant rubrics, such as asthma, chronic bronchitis, certain non-cancerous 
 diseases of bones and joints, alcoholism, and certain general diseases, have 
 been omitted. It will be noted that under the two age-groups compared nearly 
 99 per cent of the total mortality is accounted for. While this classification 
 is in the nature of the case by no means accurate, with certain reservations 
 
556 
 
 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 it will be found to conform closely enough to actual conditions to warrant use 
 for the present purpose. The main difficulty concerns the confusion that 
 naturally arises in seeking to determine the direct influence of infectious pro¬ 
 cesses upon the causation of the affections of group 1, and the reciprocal 
 influence the diseases of groups 1 and 2 upon the incidence and mortality of 
 each other. It is obvious that it is not possible to separate each and every one 
 of the primary and secondary infectious processes from groups 1, 3, and 4, 
 nor to make exact allowances for the part contributed to the mortality of the 
 affections under these groups by those belonging to group 1. However, these 
 difficulties may be overcome to a considerable degree. 
 
 First considering group 1, there is no convincing evidence that infection is 
 concerned in the causation of cancer and other tumors, chronic diseases of the 
 stomach, hernia and intestinal obstruction, prostatic hypertrophy, leucaemia 
 and essential anaemia, exophthalmic goiter, and senility. Nor are infections 
 concerned primarily in the causation of the vast majority of cases of cardio¬ 
 vascular-renal disease, cirrhosis of the liver and diabetes, and chronic diseases 
 of the nervous system. It is true that in some instances among the last-named 
 affections, syphilis is known to play a causal role. But according to the cus¬ 
 tom of the statistical division, in the case of deaths from diseases of this class, 
 such as aneurism, arteriosclerosis, chronic myocarditis, cirrhosis of the liver, 
 diabetes, locomotor ataxia, and general paralysis, inquiry was made of the 
 attending physician, and in those instances in which syphilis was acknowl¬ 
 edged to be present such deaths were classified under the rubric for syphilis, 
 and thus the error from this source was largely though not completely offset. 
 It is the exception and not the rule for clinicians (personal communication of 
 Dr. Llewellys F. Barker) or for pathological anatomists to be able to identify 
 syphilis as the cause of chronic cardio-vascular-renal disease, the most promi¬ 
 nent member of the group. In the light of recent knowledge, it seems likely 
 that in most cases in individuals over age 40 diabetes is the result of vascular 
 lesions—a type of arterio-capillary disease of certain areas in the pancreas. 
 Acute endo and pericarditis and rubrics 82, 83, 84, and 85, of which the most 
 important is 82 (thrombosis and embolism), all supposedly primary, were 
 responsible for rates of 11 and 30, respectively, for age-group 40 years and 
 over. These are easily balanced by the rubric senility, deaths classified under 
 which are due largely to breakdown of the cardio-vascular-renal system. 
 Doubtless many, if not most, of the deaths ascribed to acute and chronic disease 
 of the gall apparatus, with or without calculi, are due primarily to lesions 
 associated with infections, and this would account for most of the mortality 
 credited to “ other diseases of the liver ” and of the biliary system. Also, 
 some allowances must be made for deaths from acute Bright's disease and for 
 suppurative nephritis, renal and vescular calculi. The deductions necessary 
 for these categories are relatively insignificant. 
 
 The question of pyogenic infections occurring in the victims of violence 
 and of chronic organic diseases is of importance. The susceptibility of indi¬ 
 viduals in these conditions to pyogenic infections is well known. In some 
 instances, as in the case of gunshot wounds and crushing injuries, the relation 
 is evident, but with the chronic visceral lesions, unless the individual is bed¬ 
 ridden, it is often difficult to decide whether a complicating acute infection 
 such as lobar-pneumonia is determined by the primary disease. 
 
GENERAL CONCLUSIONS 
 
 557 
 
 When the lethal stage of a chronic visceral disease is of such character as 
 to cause obstruction to a natural outlet, as with prostatic hypertrophy, or is 
 associated with ulceration, as with some tumors, the local suppurative and 
 general infections with pyogenic micro-organisms so common in these states 
 are very evidently secondary, and no confusion arises in regard to either 
 causation of the primary lesion or to statistical classification. Similarly, the 
 proneness of individuals in the terminal stages of all of the chronic visceral 
 diseases, and especially of cardio-vascular-renal disease, cirrhosis of the liver, 
 diabetes, chronic disease of the central nervous system, leucaemia, and tumors, 
 to develop acute pyogenic infections, including broncho-pneumonia, is well 
 recognized, and the rules of statistical classification properly require that 
 deaths of such individuals be assigned to these respective rubrics of the chronic 
 organic diseases. For age-period 40 years and over, group 3 is of no impor¬ 
 tance, and group 4 (violence) is a slightly less effective cause of death than 
 before age 40. Some deaths classified as due to violence, notably from falls 
 in the aged, are really due to changes which go with senesence. 
 
 On further analysis of table 140, it is observed that the proportional dis¬ 
 tribution of mortality among the four groups and their members varies very 
 widely for the two great age-periods under consideration. The percentages 
 of total mortality for these groups were: at all ages, 44, 38, 8.5, and 6; age- 
 period 0 to 39 years, 12, 58, 19, and 7; and age-period 40 years and over, 72, 
 22, 0, and 5, respectively. The differences in the two age-periods between the 
 mortality from the infectious and from the chronic degenerative diseases are 
 very significant. After the thirty-ninth year, the pyogenic infections, pneu¬ 
 monia, tuberculosis, and influenza, are the only infectious diseases which con¬ 
 tribute significantly to mortality, and of the rest syphilis is the only one whose 
 mortality-rate is not in a comparative sense negligible. 
 
 In respect of the chronic organic diseases, for which it has been shown that 
 infection can play no very important primary etiological role, the most strik¬ 
 ing fact is the outstanding prominence of the cardio-vascular-renal system 
 as the seat of fatal lesions in individuals over the thirty-ninth year of age. 
 Next to these stands cancer, and at the foot of the list all the remaining 
 chronic organic diseases taken together. In order of their relative importance 
 as contributors to the total mortality, as expressed in percentages, they stand, 
 cardio-vascular-renal disease, 50; cancer, 12; all other chronic organic diseases, 
 10. In other words, the chronic non-cancerous degenerative organic diseases 
 were responsible for something like 60 per cent of the total mortality in this 
 age-period in 1920, and of this moiety the overwhelming proportion was due 
 to cardio-vascular-renal disease. 
 
 Since the affections in group 1 are the only ones whose incidence and mor¬ 
 tality are largely confined to age-period 40 years and over, and since the dura¬ 
 tion of life is restricted, few individuals surviving to the eightieth year and 
 hardly any reaching the hundredth year, this means that, barring accidents, 
 if the infectious diseases were entirely wiped out, the proportional importance 
 of the chronic degenerative diseases would expand correspondingly. While 
 medical and other methods of interference with the natural course of mor¬ 
 tality may and do act in some degree at all age-periods, they can, of course, 
 only postpone the inevitable, and this is the logical end of such activities. 
 Considering only those activities of this character that are brought to bear 
 
558 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 on age-group 40 years and over, it is apparent from analyses previously made 
 that little influence in this connection can be expected from the operation of 
 measures of public-health administration. The question resolves itself into 
 the influence of constitutional vigor, heredity, personal hygiene, and medical 
 and social activities. In respect of the two former categories, this material 
 throws little light, beyond the facts that on the whole the death-rate from this 
 group of diseases is higher in negroes than in whites and in males (except in 
 the case of cancer of the generative organs) than in females; that the duration 
 of life is longer in whites than in negroes; and that during the last 60 or 70 
 years, in association with and probably largely on account of the decline in 
 the mortality from the nuisance-borne diseases, from the exanthemata, from 
 tuberculosis, diphtheria, and whooping-cough among the transmissible diseases, 
 and from diseases of early infancy, a much larger proportion of the population 
 than was formerly the case attains and surpasses age 40. 
 
 The evidence at hand indicates, however, that when this type of natural 
 selection—the weeding-out by these diseases in early life of a large propor¬ 
 tion of the weak—was most effective, the members of the population who 
 attained midlife were more vigorous of constitution. It has been shown that 
 the mortality over the thirty-ninth year has risen rather than fallen during 
 the last 50 years; and from a comparative study of death-rates specific for age 
 for the various census years from 1830 to 1920, inclusive (table 136, graph 
 38), it appears that a reciprocal relationship obtained between the force of 
 mortality in early and in late life. That is, in those periods of the city’s his¬ 
 tory when the toll of mortality was particularly heavy during the first 4 or 5 
 decades of life, its rate was commonly relatively low in later life, and con¬ 
 versely, when for the reasons above mentioned, mortality became compara¬ 
 tively low in early life, the death-rate in the upper age-groups ascended to 
 higher levels. The first condition was typical of the earlier decennia of the 
 nineteenth century and the second characterized the last few decennia of that 
 century and the first two of the twentieth. In the early period those few 
 who survived the snares and pitfalls of early life were relatively tough and 
 better withstood the vicissitudes of midlife and old age. This phenomenon is 
 in agreement with the findings of Pearson (68), of Macdonald (69), and of 
 Pearl (70) in comparative studies of life-tables of ancient and modern popula¬ 
 tions, although, as is to be expected, in view of the shorter interval of time 
 involved in the present instance, these differences are less marked than in the 
 case of the comparisons of the duration of life in the respective populations 
 studied by these authors. It is evident, therefore, that during the last 50 years, 
 in consequence of decline in the forces of mortality in early life, a gradually 
 increasing ratio of the population has attained midlife, and that on the whole 
 these individuals have proved to be poorer risks and less capable of survival 
 to old age than were the proportionally smaller numbers who reached age 40 
 when natural selection was more searching in its action. 
 
 To what degree personal hygiene and changed conditions of living have 
 affected the incidence and mortality of the diseases of this group it is impossi¬ 
 ble to reckon. On the whole, no large groups of people have ever lived in such 
 conditions of comfort, protection from the cold, and had food and clothing in 
 such abundance, variety, and quality as the inhabitants of modern American 
 
GENERAL CONCLUSIONS 
 
 559 
 
 cities during the last 40 or 50 years; and in Baltimore conditions of this 
 kind have been particularly favorable. 
 
 In respect of the influence of medical activities, it is evident that modern 
 surgery has resulted in the prolongation of the lives of many individuals who 
 would otherwise have died of cancer and other tumors, of diseases of the biliary 
 and urinary passages, of prostatic hypertrophy, of ulcers of the stomach and 
 duodenum, of hernia and of intestinal obstruction, of acute infections, and of 
 various accidents. In the same manner, whatever improvements in medical 
 care and treatment that have taken place have acted in similar fashion in 
 disturbing the proportional distribution of mortality among the various 
 members of this group. It is evident, therefore, that any and all causes which 
 have been effective in prolonging life into mid-age have increased the chances 
 of death from the chronic degenerative diseases. 
 
 Since in comparison with those of the cardio-vascular-renal system chronic 
 degenerative diseases of all other organs are of minor importance, disease 
 of that system must be regarded as the normal gateway from life to death in 
 old age. During the past 50 years they have grown decidedly in importance 
 as the cause of natural death. The other members of this group, cancer and 
 other tumors included, have apparently not gained in mortality, but owing 
 partly to natural causes and partly to artificial interference, have become 
 relatively of less importance in this respect. 
 
 At this point a very pertinent question arises. Why is it that the large and 
 small organs (the kidneys excepted) of both internal and external secretion 
 and the ducts of some of them, together with the skin, the brain, the locomotor 
 apparatus, and the sex organs, are, in comparison with the cardio-vascular- 
 renal so rarely the seat of chronic degenerative processes incompatible with 
 continued life? A partial explanation lies in the fact that the former are 
 more commonly the seat of benign and malignant tumors which, in the classi¬ 
 fication of mortality arbitrarily adopted here, are withdrawn from both 
 categories. This circumstance confers an artificial advantage upon the cardio- 
 vascular-renal system. However, when full allowance is made for this, the 
 proportional distribution of mortality is still heavily against the latter system. 
 Omitting from consideration for the moment the influence of sex, in propor¬ 
 tion to their liability to give origin to fatal cancer after age 40, the organs, 
 of the body, arranged according to the embryological derivation of their most 
 highly differentiated or characteristic cells, rank in the following order of 
 frequency: endoderm, ectoderm, mesoderm. The cardio-vascular-renal sys¬ 
 tem shares with other structures of mesodermal origin in a relative immunity 
 to cancer. It is from the cells of endodermic origin in the highly differentiated 
 glandular organs that cancer most frequently springs. Next in frequency 
 stand cancers arising from the skin and other organs whose most character¬ 
 istic cells are of ectodermal origin. The relatively higher mortality from 
 benign and malignant tumors in the female is due very largely to a peculiar 
 liability of this sex to such growths of two organs of mesodermal origin, i. e., 
 the uterus and ovaries, and of the ectodermal tissues of the cervic uteri and 
 of the breast. The higher mortality of the female from cancer of the latter 
 organ is to a considerable degree offset by the greater proneness of the male 
 to develop cancer from the other ectodermic structures, such as the skin, the 
 lips, and the buccal mucosa. 
 
560 PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 For the rest, the comparatively greater vulnerability of the cardio-vascular- 
 renal system in those who survive the fortieth year must depend upon attributes 
 associated with structure, function, and extent of surface. Considering these 
 factors in inverse order, it is apparent that, taking into account the heart, 
 arteries, capillaries, veins, and the parenchyma of the kidneys, in surface, 
 the cardio-vascular-renal system must exceed the various visceral organs 
 most subject to chronic degenerative lesions other than cancer. In bulk, also, 
 the comparison is probably in favor of the cardio-vascular-renal system. In 
 both design and in function this system has the disadvantages as well as the 
 advantages of a highly coordinated mechanical apparatus. During life the 
 heart in its capacity as a force and suction pump never ceases in its alternate 
 phases of rhythmical contraction and relaxation, by which it keeps in circula¬ 
 tion, under considerable though varying pressure through the arteries, capil¬ 
 laries, and veins of a double system, a viscid fluid, heavily laden with cells. 
 The vascular portion of the circulatory system and the kidneys work with¬ 
 out cessation. 
 
 The lining cells of the heart and vessels and the renal epithelial cells are 
 delicately organized and highly differentiated for a variety of functions, and 
 are submitted to the action of numerous and varied poisons. The valve seg¬ 
 ments of the heart are delicately thin and but poorly vascularized. The rings 
 of the four cardiac orifices are but inadequately braced to withstand the great 
 pressures to which they are often subjected. The muscle-cells are highly 
 differentiated, and the mechanism through which the coordination of their 
 rythmical contractions is controlled is delicate and one easily disarranged by 
 the stretching of the vascular rings and by other lesions. Through the med¬ 
 ium of the vagus nerve the rate of the heart-beats is subject to interferences 
 by stimuli from the central nervous system and from conditions acting upon 
 the nerve itself. The elastic tissue of the intima and the fibro-elastic-muscular 
 media of the arteries frequently give way to constant and abnormally high 
 pressures and are susceptible to the action of a number of injurious agents. 
 Of all the glandular organs of external secretion, the kidneys are the largest 
 and the most highly differentiated. Far removed from the heart, they are 
 interpolated on the vascular system as excretory organs, through which passes 
 in a given time a large quantity of blood over an extensive and complicated 
 vascular area. In the kidneys, as in the case of the heart and the brain, inter¬ 
 communication among the smaller branches of the main arterial branches is 
 not so free as in other important organs. In consequence, lesions of the arteries 
 of these important organs, such as dilatations, narrowings, obliterations, rup¬ 
 tures, and the like, which are not infrequent, are fraught with more serious 
 results than in other organs. 
 
 Though capable of considerable reparation after overwork and other injury 
 and of varieties and degrees of adaptation and compensation under mechani¬ 
 cal stresses, and in the face of serious lesions that are little short of marvelous, 
 in proportion to the burdens it is called upon to bear the cardio-vascular-renal 
 system of the average individual can not be classed as designed to withstand 
 for an indefinite time the strain and stress it is called upon to bear in normal 
 life. Whatever the history in respect to previous disease and abuses, it is 
 uncommon to find at autopsy on an individual of 40 or 50 years of age and 
 
GENERAL CONCLUSIONS 
 
 561 
 
 dead of any cause, even accident, perfectly normal arteries, heart, and kidneys. 
 Above age 60, whatever the history of the individual and the cause of death, 
 extensive changes in the kidneys, arterial system, and heart are to be expected; 
 and in the aged, widespread and grave lesions of these organs are nearly 
 always present. Indeed, these changes are as characteristic of old age as is 
 wrinkling of the skin. 
 
 That the changes of arterio-sclerosis are in part due to wear and tear in 
 keeping up the blood-pressure throughout life is exemplified by the fact that, 
 whatever the age of the individual or his history of previous diseases and 
 excesses, sclerotic changes of the type occurring in advanced arterio-sclerosis 
 are very rarely found in the venous system in which the blood-pressure is 
 normally low. When, under very exceptional circumstances, venous sclerosis 
 does occur, it is commonly localized in some one vein and evidently the result 
 of some particular injury. While a number of different degenerative lesions 
 have been observed in developing arterio-sclerosis and the reactions of repair 
 and compensation on the part of the arteries, the kidneys, and the heart and 
 the mechanism of the circulation through all stages of the process are fairly 
 well understood, pathological anatomists are not in agreement in the interpre¬ 
 tation of the sequences and interrelations of the various degenerative and 
 reparative processes of the common non-syphilitic arterio-sclerosis. 
 
 In regard to causation, except that the slowly developing senile type is part 
 and parcel of senesence, and that there is a relatively rare but quite character¬ 
 istic syphilitic type, accurate knowledge is lacking. Certain it is, however, 
 that very occasionally in the relatively young and very commonly in persons, 
 both male and female, between 40 and 55 years of age, a very definite type of 
 illness begins with high blood-pressure and ends usually in a few months or 
 years with the clinical signs and anatomical lesions of arterio-sclerosis and 
 nephritis and often of the cardiac valves and of the myocardium. In another 
 class of cases disease begins as a primary nephritis and often ends in death 
 with or without extensive vascular and cardiac lesions. In the typical senile 
 form, when not complicated with some acute infection, death commonly fol¬ 
 lows apoplexy, renal or cardiac insufficiency, or an attack of angina pectoris. 
 These and other accidents involving the cardio-vascular-renal apparatus occur 
 in all types of the disease. One of the most characteristic concomitants of 
 general arterio-sclerosis, especially in individuals between the fortieth and 
 sixtieth years of life, is the enormous cardiac hypertrophy which is due to the 
 increased work demanded of the heart to carry on the circulation under the 
 new conditions of pressure which are determined in part at least by the 
 arterial changes. 
 
 Finally to be considered are the cases of true endocarditis, usually of the 
 valves, and which is commonly secondary to some acute infection. It is 
 obvious that in fatal cases of cardio-vascular-renal disease physicians ascribe 
 death to the lesion which is or seems to be the more prominent at the terminal 
 stage, and hence the variety of terms used in medical nosology to cover these 
 protean lesions. To a great degree the use of particular terms, such as fatty 
 heart, heart failure, heart hypertrophy, decompensation, hypertension, and 
 the like, are determined by transitory fashions. So it is clear that, by design, 
 structure, and the nature of its function, the cardio-vascular-renal system 
 
562 • PUBLIC HEALTH ADMINISTRATION, ETC., IN BALTIMORE 
 
 is unsuited to stand indefinitely the strains, stresses, and accidents to which 
 it is subjected, its very extent in surface constitutes a mass of tissue far 
 greater in dimension than any other viscus, the character of its lesions cause 
 great impairment of its functions, and the accidents to which it is subject 
 are often necessarily fatal. 
 
 Attention has been directed to the fact that certain infectious diseases, 
 notably pneumonia, both lobar and broncho, tuberculosis, influenza, and the 
 pyogenic infections, display rising mortality-rates after age 40, and it is 
 well established that all of these affections are particularly common in the 
 terminal stages of the chronic visceral diseases, and particularly of those of 
 the cardio-vascular-renal system. This association does not, however, prove 
 that these chronic organic diseases per se always determine incidence and 
 fatality, for at least two other possible causes of lack in resistance with advanc¬ 
 ing age must be considered—decrease in organ immunity and in the general 
 immunity provided by the usual mechanisms, whatever they may be. 
 
 That loss of organ immunity plays a large part here is evident when con¬ 
 sideration is given to the fact that the various organs are affected in great 
 disproportion, i. e., the lungs, the skin, and the genito-urinary system, espe¬ 
 cially in the male, very commonly, while the liver, pancreas, stomach and 
 intestines, the central nervous system, and above all the cardio-vascular-renal 
 system, in comparison preserve in very high degree their normal organ 
 immunity to these processes. With advancing age the skin and the pulmonary 
 system return in respect of weak resistance to attack and lethal force by the 
 pyogenic cocci and the causal agent of pneumonia to the status that obtains in 
 infancy. The asthenic character of the inflammatory reactions to local infec¬ 
 tions in old age, and the frequency with which the latter are attended by 
 general bacteriamias, often accompanied by multiple foci of inflammation, 
 indicate that in this period of life there occurs a deficiency in the various 
 defensive agents supplied by the body to the blood and lymph. 
 
 The high correlation between the lethal force of influenza and of cardio- 
 vascular-renal disease (heart disease) pointed out by Bertillon (64) and by 
 Pearl (65) and the high correlation between old age and the fatality of pneu¬ 
 monia, long recognized, are indicative perhaps of the same thing, namely, 
 lowered resistance due to changes incident to advanced age, heart disease in 
 the correlation with influenza really standing for old age. In the discussion 
 of influenza it was pointed out that a large proportion of the fatal cases of this 
 disease are complicated with pneumonia, and that under the rules those with 
 broncho-puneumonia are classified under influenza and those with lobar- 
 pneumonia are ascribed to the latter rubric. Doubtless many individuals in 
 the upper decades of life who are credited with dying of pulmonary tubercu¬ 
 losis actually die of cardio-vascular-renal disease natural to old age and with 
 the lesions of chronic tuberculosis developed earlier in life, and in itself con¬ 
 sistent with continued life. 
 
 The sexual cycle has apparently nothing to do with longevity as determined 
 by chronic organic disease for woman, whose sexual life-period, as tested by 
 capacity to reproduce, is much shorter than that of man, preserves after mid¬ 
 life her initial superior life expectancy, and exhibits in old age no higher 
 death-rates than man from the chronic organic diseases (cancer of the genera¬ 
 tive organs excepted) and a lower mortality from pneumonia. 
 
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 1897, by William Travis Howard, Senior. Manuscript copy in the possession 
 of the'present writer. 
 
 57. Amoebic dysentery. Councilman and Lafleur, Johns Hopkins Hospital Reports, 
 
 Vol. ii, 1891. 
 
 58. Gastric, or more properly, intestinal fever. E Geddings, M. D. North American 
 
 Archives of Medical and Surgical Science, Vol. I, No. 1, October, 1834. 
 
 59. The natural history of typhoid fever in Baltimore, 1851-1919. William Travis 
 
 Howard, Jr. Johns Hopkins Hospital Bulletin, August-September, 1920. 
 
 60. On the anomalous character of measles in 180&. Nathaniel Potter, M.D. Baltimore 
 
 Med. and Philosoph. Lyceum, 1811, p. S3. 
 
 61. An inquiry into the nature, cause and cure of croup. Dr. Home, Edinburgh, 1765. 
 
 62. Angina suffacotiva, or sore-throat distemper. Samuel Bard, Philosp. Soc. Trans. 
 
 Philadelphia, 1789. 
 
 63. The causation of diphtheria. William H. Welch, M.D. Tr. Med. & Chirurgical 
 
 Faculty of Maryland, Baltimore, 1891. 
 
 64. La grippe a Paris, et dans quelques autres villes de France et de l’etranger en 1889- 
 
 1890. Jacques Bertillon, Extrait de ’Annuaire statistique de la ville Paris pour 
 l’annee 1890. 
 
 65. Influenza Studies I. On certain general statistical aspects of the 1918 epidemic in 
 
 American cities. Raymond Pearl. Public Health Reports, Vol. 34, pp. 1743-1783. 
 
 66. The real risk rate of death to mothers from causes connected with childbirth. 
 
 William Travis Howard, Jr. Amer. Journ. of Hygiene, Vol. I, No. 2, March, 1921. 
 
 67. Formulae selectae of Doctors Samuel K. Jennings and Thomas Owings of Balti¬ 
 
 more, collected by the latter between 1808 and 1825. A manuscript volume 
 presented to the present writer by Dr. Arthur L. Browne. 
 
 68. On the change in the expectation of life in man during a period of circa 2000 years. 
 
 Karl Pearson, Biometrika, Vol. I, pp. 261-264, 1902. 
 
 69. On the expectation of life in ancient Rome, and in the provinces of Hispania and 
 
 Lusitania and Africa. W. R. MacDonell, Biometrika, Vol. IX, pp. 366-3S0, 1913. 
 
 70. The biology of death. Raymond Pearl, pp. 86-92, Philadelphia, 1922. 
 
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